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Home My WebLink AboutDoc 364 - Telecare AgrmtDeschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701·1960 (541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org AGENDA REQUEST & STAFF REPORT For Board Business Meeting of August 7,2013 DATE: July 29, 2013 FROM: Lori Hill, Adult Treatment Program Manager Phone: 322-7535 Health Services, Behavioral Health Division TITLE OF AGENDA ITEM: Consideration of Board Signature of Document #2013-363, Agreement between Telecare Mental Health Services of Oregon, Inc. and Deschutes County Health Services (DCHS). PUBLIC HEARING ON THIS DATE? No BACKGROUND AND POLICY IMPLICATIONS: Telecare Mental Health Services of Oregon, Inc. (Contractor) provides 24-hour secure residential treatment facilities for individuals with mental or emotional disorders who have been hospitalized and need services to avoid further hospitalization because they are a danger to themselves or others. T elecare shall provide services for up to sixteen (16) residents that have been jointly approved by County and Telecare. The purpose of secured residential treatment services is to stabilize resident's psychiatric symptoms, improve independent living skills, and then discharge the resident into an appropriate and safe level of community services of less intensity as clinically appropriate. Telecare will invoice Division of Medical Assistance Programs (DMAP) in accordance with procedures and forms prescribed by the Oregon Health Authority (OHA). County agrees to pay Telecare funds that are received by County through OHA by amendment to the contract between Deschutes County and OHA. Funding for operation and facilities will be in accordance with a budget submitted by Telecare to OHA and County and approved by both OHA and County. FISCAL IMPLICATIONS: Maximum compensation is $2,520,000. RECOMMENDATION &ACTION REQUESTED: Behavioral Health requests approval. ATTENDANCE: Lori Hill, Adult Treatment Supervisor DISTRIBUTION OF DOCUMENTS: Executed copies to: Nancy Mooney, Contract SpecialiSt. Health Services DESCHUTES COUNTY DOCUMENT SUMMARY (NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form electronically to the Board Secretary.) Please complete all sections above the Official Review line. Date: I August 13, 2013 I Department: I Health Services, Behavioral Health I Contractor/Supplier/Consultant Name: I Telecare Mental Health Services of Oregon, Inc.1 Contractor Contact: I Dwain Connolly Contractor Phone #: I 510-337-7950 Type of Document: Personal Services Contract Goods and/or Services: Telecare provides 24-hour Residential Treatment Home (RTH) services for up to ten (10) residents. Background &History: Residential Treatment Services are behavioral health services delivered on a 24-hour basis to individuals eighteen (18) years of age or older with mental or emotional disorders who have been hospitalized, who are at immediate risk of hospitalization, who need continue services to avoid hospitalization or who are a danger to themselves or others or who otherwise require continuing care to remain in the community. Residential Treatment Services include services delivered to individuals who the County, in conjunction with the Oregon Health Authority (OHA) has determined are unable to live independently without supervised intervention, training or support and are eligible for services funded under this Agreement. Telecare will invoice Division of Medical Assistance Programs (DMAP) in accordance with procedures and forms prescribed by OHA. County agrees to pay Telecare funds that are received by County through the Oregon Health Authority (OHA) by amendment to the contract between Deschutes County and OHA. The maximum compensation reflected in this contract is through December 31,2013. Any funding beyond December 31 will be stated in an amendment to the contract. Agreement Starting Date: I July 1, 2013 Ending Date: I June 30, 2014i Annual Value or Total Payment: I Maximum compensation is $592,500. : 8113/2013 Check all that apply: o RFP, Solicitation or Bid Process o Informal quotes «$150K) ~ Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37) Funding Source: (Included in current budget? ~ Yes 0 No If No, has budget amendment been submitted? 0 Yes 0 No Is this a Grant Agreement providing revenue to the County? 0 Yes ~ No Special conditions attached to this grant: Deadlines for reporting to the grantor: If a new FTE will be hired with grant funds, confirm that Personnel has been notified that it is a grant-funded position so that this will be noted in the offer letter: 0 Yes 0 No Contact information for the person responsible for grant compliance: Name: Phone#: I i Departmental Contact and Title: I Nancy Mooney, Contract Specialist I Phone #:: 541-322-7516 I Deputy Director Approval: ?--IY-I-=j Date Oi 'D \5'3 • Date Distribution of Document: Department. Department Director Approval: -----'~fL--J~:------ Nancy Mooney, Behavioral Health Official Review: County Signature Required (check one): W Boee 0 Department Director (if <$25K) Document Number 2013-364 ~~~~------------ -)a rL I? ?I I 7leJ$ aG~~Bt.'l-. ..ko! L~#=-10((-'lIN If~;;.,.~ (f' /z> ~ht, ~J 4)/ i1!(11 ,'I, 1:;-4(/..1. ~ 8/13/2013 REVIEWED LEGAL COUNSEL For Recording Stamp Only DESCHUTES COUNTY SERVICES AGREEMENT AGREEMENT NO. 2013-364 This Agreement (the "Agreemenf') is made and entered into by and between Deschutes County, a political subdivision of the State of Oregon, acting by and through the Deschutes County Health Services Department, Behavioral Health division, hereinafter referred to as "County," and Telecare Mental Health Services of Oregon, Inc., 1080 Marina Village Pkwy, Suite 100, Alameda, CA 94501, hereinafter referred to as "Contractor." WHEREAS, Contractor has acquired two properties to be licensed as residential treatment homes that have been approved by County and State of Oregon (hereinafter referred to as "Facilities") for Individuals enrolled in behavioral health programs; and WHEREAS, the parties agree that residential treatment homes is a preferred behavioral health care model in Central Oregon to provide residential behavioral health services; WHEREAS, Contractor owns, manages and is capable of operating the Facilities; and WHEREAS, County is authorized pursuant to ORS 430.670 to obtain, by contract, the services necessary to operate a community behavioral health program; and WHEREAS, Contractor has available staff for the performance of the services described in this Agreement; and WHEREAS, Contractor has obtained and shall continue to qualify for approval from the State of Oregon, Oregon Health Authority ("OHA") for purposes of providing services under this Agreement; now, therefore, IT IS HEREBY AGREED by and between the parties above mentioned, for and in consideration of the mutual promises hereinafter stated as follows: 1. Effective Date. The effective date of this Agreement shall be July 1, 2013. Unless extended or terminated earlier in accordance with its terms, this Agreement shall terminate when County accepts Contractor's completed performance or on June 30, 2014, whichever date occurs last. Agreement termination shall not extinguish or prejudice County's right to enforce this Agreement with respect to any default by Contractor that has not been cured. 2. Contractor's Services. Contractor shall provide 24-hour Residential Treatment Home (RTH) services for up to ten (10) residents that have been jointly approved by County and Contractor. Contractor shall provide RTH services described in the attached Service Description, titled "Residential Treatment Services", Service ID code MHS 28, Exhibit 1A and in accordance with OAR 309-035-0250 through 309 035-0460, in the Facilities. Contractor shall also provide out-patient mental health services to RTH residents in accordance with OAR 309-16-0600 through 309-016-0685 "Medicaid Payment for Rehabilitative Mental Health Services and OAR 309-032-1500 through 309-032-1565 "Integrated Services and Supports Rule". Contractor shall screen and assess Individuals for tobacco use, and offer tobacco cessation resources to Individuals choosing to quit. 3. Regulations and Duties. Contactor shall comply with all applicable provisions, including applicable Service V Descriptions attached thereto, in place at the time this Agreement is executed and effective July 1, 2013, , I I the "Contract") between the Oregon Health Authority ("OHA") and Deschutes County, as the same may be amended, replaced and/or renewed from time to time. Contractor agrees to comply with the rules and regulations of County, applicable provisions in the Contract between County and the OHA, incorporated herein by reference. as of the effective date of such regulations, applicable provisions of the Administrative I , Rules and Procedures of the OHA, applicable Federal regulations and all provisions of Federal and State statutes, rules and regulations relating to Contractors performance of services under this Agreement. Any PAGE 1 OF 9 DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 DC -2 a1 3 -3 6 d~ act or duty of County, imposed upon County by OHA, which, by the nature of this Agreement, County determines to be within the scope of this Agreement and is to be performed by Contractor, Contractor shall perform on behalf of County. No federal funds may be used to provide services in violation of 42 U.S.C. 14402. 4. Reporting. A. Contractor shall provide County with periodic reports at the frequency and with the information prescribed by County. Further, at any time, County has the right to demand adequate assurances that the services provided by Contractor shall be in accordance with the Contract. Such assurances provided by Contractor shall be supported by documentation in Contractor's possession from third parties. B. Contractor agrees to prepare and furnish such reports and data as may be required by County and the Oregon Health Authority, including but not limited to an Individual's records which contain the Individual's identification, problem assessment, Service and Support Plan (including any training and/or care plan), appropriate medical information, and Service Notes, including a service termination summary and current assessment or evaluation instrument as designated by the Oregon Health Authority in the administrative rules. Contractor shall retain an Individual's records in accordance with OAR 166-150-0005 through 166-150-0215 (State Archivist). Unless OAR 166-150-0005 through 166 150-0215 requires a longer retention period, an Individual's records must be retained for a minimum of ten (10) years from termination or expiration of this Agreement. It is understood that due to the limited nature of Contractor's services under this Agreement, not all of these documents will have been prepared by Contractor and therefore need not be furnished. Oregon Health Authority Client Process Monitoring System (CPMS) data, Community Mental Health Provider Report, and Termination Service Recording Form shall, if necessary, be completed in accordance with Oregon Health Authority requirements and submitted to Oregon Health Authority through County. Contractor agrees to, and does hereby grant County and the Oregon Health Authority the right to reproduce, use and disclose for County or Oregon Health Authority purposes, all or any part of the reports, data, and technical information furnished to County under this Agreement. Contractor shall make available to County, Oregon Health Authority and any Individual enrolled in and/or seeking services from Contractor as defined in Exhibit 1, of this Agreement, any and all written materials in alternate formats in compliance with Oregon Health Authority's policies or administrative rules. For purposes of the foregoing. "written materials" includes, without limitation, all work product and contracts related to this Agreement. C. Contractor shall submit reports as requested by County. All notices, bills and payments shall be made in writing and may be given by personal delivery or by mail. Notices, bills, and payments sent by mail should be addressed as follows: Contractor: Telecare Mental Health Service of Oregon, Inc. 1080 Marina Village Pkwy. Suite 100 Alameda, CA 94501 Attn: Marshall Langfeld Phone: (510) 337-7950 County: Deschutes County Health Services 2577 NE Courtney Dr. Bend, OR 97701 Attn: Lori Hill Phone: (541) 322-7535 5. Access to Records. Contractor shall maintain fiscal records and all other records pertinent to this Agreement. A. All fiscal records shall be maintained pursuant to generally accepted accounting standards, and other records shall be maintained to the extent necessary to clearly reflect actions taken. 1) Contractor shall retain and keep accessible all books, documents, papers and records that are directly related to this Agreement, the funds paid to Contractor hereunder or to any services delivered hereunder, for a minimum of seven (7) years, or such longer period as may be required by other provisions of this Agreement or applicable law, following the termination or expiration of this Agreement. PAGE 2 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 2) If an audit, litigation or other action involving this Agreement is started before the end of the seven-year (7) period. the records shall be retained until all issues arising out of the action are resolved. B. County, the Oregon Health Authority. the Secretary of State's Office of the State of Oregon, the Federal Government. and their duly authorized representatives shall have the right to direct access to all of Contractor's books, documents, papers and records related to this Agreement, the funds paid to Contractor hereunder, or any services delivered hereunder for the purpose of conducting audits and examinations, making copies, excerpts and transcripts. In addition, Contractor shall permit authorized representatives of County and the Oregon Health Authority to perform site reviews of all services delivered by Contractor hereunder. 1) These records also include licensed software and any records in electronic form, including but not limited to computer hard drives, tape backups and other such storage devices. County shall reimburse Contractor for Contractors cost of preparing copies. 2) At Contractors expense, the County. the Secretary of State's Office of the State of Oregon, the Federal Government. and their duly authorized representatives. shall have license to enter upon Contractor's premises to access and inspect the books, documents, papers. computer software, electronic files and any other records of the Contractor which are directly pertinent to this Agreement. 3) If Contractor's dwelling is Contractors place of business, Contractor may, at Contractor's expense, make the above records available at a location acceptable to the County. 6. Confidentiality. Contractor shall maintain confidentiality of information obtained pursuant to this Agreement as follows: A Contractor shall not use, release or disclose any information Contractor shall not use, release or disclose any information concerning any employee, Individual, applicant or person doing business with the County for any purpose not directly connected with the administration of County's or the Contractor's responsibilities under this Agreement except upon written consent of the County. and if applicable, the employee, Individual, applicant or person. B. The Contractor shall ensure that its agents, employees, officers and subcontractors with access to County and Contractor records understand and comply with this confidentiality provision. C. Contractor shall treat all information as to personal facts and circumstances obtained on Medicaid eligible individuals as privileged communication. shall hold such information confidential. and shall not disclose such information without the written consent of the individual. his or her attorney. the responsible parent of a minor child. or the child's guardian, except as required by other terms of this Agreement. D. Nothing prohibits the disclosure of information in summaries. statistical information. or other form that does not identify particular individuals. E. Personally identifiable health information about applicants and Medicaid recipients will be subject to the transaction, security and privacy provisions of the Health Insurance Portability and Accountability Act ("HIPAA"). F. Contractor shall cooperate with County in the adoption of policies and procedures for maintaining the privacy and security of records and for conducting transactions pursuant to HIPAA reqUirements. G. This Agreement may be amended in writing in the future to incorporate additional requirements related to compliance with HIPAA. H. If Contractor receives or transmits protected health information, Contractor shall enter into a Business Associate Contract with County, which. if attached hereto. shall become a part of this Agreement. I. Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health Information relating to specific individuals may be exchanged between County PAGE 3 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 and OHA for purposes directly related to the provision of Services to Individuals which are funded in whole or in part under this Agreement. Contractor shall maintain the confidentiality of Individual records as required by applicable state and federal law, including without limitation, ORS 179-495 to 179.507, 45 CFR Part 205, 42 CFR Part 2, any administrative rule adopted by the Oregon Health Authority, implementing the foregoing laws, and any written policies made available to Contractor by County or by the Oregon Health Authority. Contractor shall create and maintain written policies and procedures related to the disclosure of Individual information and shall make such policies and procedures available to County and the Oregon Health Authority for review and inspection as reasonably requested by County or the Oregon Health Authority. 7. County Monitoring and Site Visits. Contractor agrees that services provided under this Agreement by Contractor, Facilities used in conjunction with such services, Individual records, Contractors policies, procedures, performance data, financial records, and other similar documents and records of Contractor, that pertain, or may pertain, to services under this Agreement, shall be open for inspection by County, or its agents, at any reasonable time during business hours. Contractor agrees to retain such records and documents for a period of ten (1 O) years, or such longer period as may be prescribed for such records and documents by the State of Oregon Archivist or until the conclusion of any dispute or proceeding related to the services under this Agreement or involving the records of Contractor, whichever is longer. Contractor shall permit County and OHA to make site visits upon reasonable notice to monitor the delivery of services under this Agreement. 8. Payment of Agreement. Subject to availability of funds, Contractor will receive payment for providing the services described in Exhibit 1. A Contractor shall bill DMAP in accordance with procedures and forms prescribed by OHA for all Part B funds (as defined in Exhibit 1) that are approved by OHA as part of Contractor's budget. Contractor agrees that payment for these services shall be DMAP's responsibility and not County's responsibility. Contractor shall not invoice or expect payment from County for services billed to DMAP under this subsection. 1) All Extended Care Services reimbursable service billings shall be in accordance with OHA Medicaid General Provider Rules 410-120-0000 through 410-120-1940 and MHS Mental Health and Developmental Disability Services Medicaid Payment for Rehabilitative Mental Health Services Rule as listed in OAR 309-016-0600 through 309-016-0685. 2) Contractor shall bill all Personal Care Services in accordance with forms and procedures prescribed by OHA 3) Contractor agrees to complete, monitor and obtain all prior authorizations as needed for Extended Care Service and Personal Care Service billing submissions. B. County agrees to pay to Contractor, all "Part An funds received by County which are allocated by OHA for services (described in Exhibit 1) provided by Contractor or are expenditures approved by OHA in Contractor's budget. 1) Contractor agrees to invoice County on a monthly basis for all Part A funds that are approved by the OHA as part of Contractor's budget and paid to the County by amendment to the contract. County agrees to make approved payments to Contractor within thirty (30) days of receipt of invoice. 2) Contractor agrees to complete and submit all documentation of expenditures for Part A funds as required by OHA and County and to comply with all requirements of the Service Description in which funding is allocated. C. Any extension of services for the period after June 30,2014 will be by separate agreement. 9. Payments in Future Years beyond June 30, 2014. Not later than April 2014, Contractor and County shall meet to review this Agreement and negotiate the program and reporting requirements, protocols and payment to be paid by County and OHA to Contractor beginning after July 1, 2014. The parties may at that time also negotiate payment methods and amounts for one or more years after 2014. 10. Recovery of Funds. Expenditures of Contractor may be charged to this Agreement only if they: (1) are in payment for services performed under this Agreement; (2) conform to applicable State and Federal regulations and statutes; (3) are in payment of an obligation incurred during the period of this Agreement; PAGE 4 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 and (4) when added to other compensation pursuant to this Agreement are not in excess of 100% of the maximum amount detailed in Exhibit 1. If Contractor fails to provide an acceptable audit performed by a certified public accountant for federal funds received under this Agreement, or if federal authorities demand the repayment of federal funds received under this Agreement, County may recover all federal funds paid under this Agreement, unless a smaller amount is disallowed or demanded. If OHA disallows or requests repayment for any funds paid under this Agreement due to Contractors' acts or omissions, Contractor shall make payment to the County of the amount OHA disallows or requests repayment. In the event that the OHA determines that County is responsible for the repayment of any funds owed to the OHA by Contractor, Contractor agrees to make such payment within ten (10) days of notification by County or the OHA of said determination by the OHA. 11. Retention of Revenue and Earned Interest. Fees and third-party reimbursements, including all amounts paid pursuant to Title XIX of the Social Security Act by the OHA, for services rendered by Contractor, and interest eamed on such funds in the possession of Contractor, shall be retained by Contractor provided that such amounts are received on account a behavioral health service described in Exhibit 1 of this Agreement and complies with the standards of the OHA. 12. Withholding of Payments. Notwithstanding any other payment provision of this Agreement, should Contractor fail to submit required reports required by Section 4(A) and Exhibits 1, 2 and 3 when due, or fail to perform or document the performance of contracted services, County shall immediately withhold payments under this Agreement until the required reports have been submitted by the Contractor. 13. Termination. All or part of this Agreement may be terminated by mutual consent of both parties, or by either party at any time for convenience upon ninety (90) days notice in writing to the other party. The County may also terminate a" or part of this Agreement for any of the causes speCified below: A. With thirty (30) days written notice, if funding to the County from Federal, State, or other sources is not obtained or is not continued at levels suffiCient to allow for purchase of the indicated quantity of services. The County will give more notice whenever possible. B. With sixty (60) days written notice, if Federal or State regulations are modified or changed in such a way that services are no longer allowable for purchase under this Agreement. C. Upon notice of denial, revocation, or non-renewal of any letter of approval, license, or certificate required by law or regulation to be held by the Contractor to provide a service element under this Agreement. D. With thirty (30) days written notice, if Contractor fails to provide services, or fails to meet any performance standard as specified by the County in this Agreement (or subsequent modifications to this Agreement) within the time specified herein, or any extensions thereof. E. Upon written or oral notice, if County has evidence that the Contractor has endangered or is endangering the health and safety of Individuals, residents, staff, or the public. F. Failure of the Contractor to comply with the provisions of this Agreement or any applicable Federal, State and local laws and rules which may be cause for termination of this Agreement. The circumstances under which this Agreement may be terminated by either party under this paragraph may involve major or minor violations. Major violations include, but are not limited to: 1) Acts or omissions that jeopardize the health, safety, or security of Individuals. 2) Misuse of funds. 3) Intentional falsification of records. In the case a failure to perform jeopardizes the safety and security of any residents of the facilities covered under this Agreement, the Contractor, the County and the OHA shall jOintly PAGEl OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 conduct an investigation to determine whether an emergency exists and what corrective action will be necessary. Such investigation shalt be completed in accordance with OHA procedures and the Agreement. The Contractor may also terminate all or part of this Agreement With thirty (30) days written notice, if the "Part An funding is not paid to Contractor as outlined in 8(8). 14. Encumbrance or Expenditure After Notice of Termination. Contractor shalt not make expenditures, enter into contracts, or encumber funds in its possession that belong to the County, after notice of termination or termination as set out above, without prior written approval from County. 15. Independent Contractor. Contractor is engaged hereby as an independent contractor, as defined in ORS 670.600 and will be so deemed for purposes of the following: A. Contractor will be solely responsible for payment of any Federal or State taxes required as a result of this Agreement. 8. Contractor shall be solely responsible for and shall have control over the means, methods, techniques, sequences and procedures of performing the work, and shall be solely responsible for the errors and omissions of its employees, subcontractors and agents. For goods and services to be provided under this Agreement, Contractor agrees to: 1) perform the work in a good, workmanlike, and timely manner; 2) comply with all applicable legal requirements; 3) take all precautions necessary to protect the safety of all persons at or near facilities, including employees and patients of Contractor and County; 4) take full responsibility for wages and entitlements of Contractor's employees assigned to or furnishing services at facilities. C. It is agreed by and between the parties that Contractor is not carrying out a function on behalf of the County, OHA or State of Oregon, and County, OHA and State of Oregon do not have the right of direction or control of the manner in which Contractor delivers services under this Agreement or exercise any control over the activities of the Contractor. Contractor is not an officer, employee or agent of County as those terms are used in ORS 30.265. D. County is not, by virtue of this Agreement, a partner or joint venturer with Contractor in connection with activities carried on under this Agreement, and shall have no obligation with respect to Contractor's debts or any other liabilities of each and every nature. Unless Contractor is a State of Oregon governmental agency, Contractor agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Health Authority or County. E. The Contractor is an independent contractor for purposes of the Oregon Workers' Compensation law (ORS Chapter 656) and is solely liable for any Workers' Compensation coverage under this Agreement. 16. Contractor and Subcontractors. Contractor agrees to make all provisions of this Agreement with the County applicable to any subcontractor performing work under this Agreement. Contactors who perform the work without the assistance of labor or any employee, as determined under ORS Chapter 656 and rules adopted pursuant thereto, need not obtain Workers Compensation coverage. 17. Constraints. A. The Provisions of ORS 2798.220, 2798.230, and 2798.235, are by this reference incorporated and made a part of this Agreement: 1) Contractor shall pay employees for overtime work performed under this Agreement in accordance and otherwise comply with applicable provisions of ORS 653.010 to 653.261 and the Fair Labor Standards Act of 1938 ("FLSA") (29 U.S.C 201 et. seq.). PAGE 6 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 B. This Agreement is expressly subject to the debt limitation of Oregon counties set forth in Article XI, Section 10, of the Oregon Constitution, and is contingent upon funds being appropriated therefore. Any provisions herein, which would conflict with law, are deemed inoperative to that extent. C. Contractor agrees that no person shall, on the grounds of race, color, creed, national origin, sex, marital status, or age, suffer discrimination in the performance of this Agreement when employed by Contractor. Unless exempted under the rules, regulations and relevant orders of the Secretary of Labor, 41 CFR, Chapter 60, Contractor agrees to comply with (i) all provisions of Executive Order No. 11246, as amended by Executive Order No. 11375 of the President of the United States dated September 24, 1965 as supplemented in Department of Labor regulations (41 CFR Part 60), (ii) Titles VI and VII of the Civil Rights Act of 1964 as amended, (iii) Sections 503 and 504 of the Rehabilitation Act of 1973 as amended and 45 CFR 84.4, which states, "No qualified person shall, on the basis of handicap, be excluded from participation in, be denied benefits of, or otherwise be subjected to discrimination under any program or activity which receives or benefits from Federal financial assistance" (iv) the Age Discrimination in Employment Act of 1974, as amended, and the Age Discrimination Act of 1975, as amended (v) the Vietnam Era Veterans' Readjustment Assistance Act of 1975, (vi) all applicable rules regulations and order of the Secretary of Labor concerning equal opportunity in employment and the provisions of ORS Chapters 659 and 659A (vii) Title II of the Americans with Disabilities Act of 1990 as amended (42 USC 12131 et. Seq.), ORS 30.670 to 30.685, and all regulations and administrative rules established pursuant to those laws in the construction, remodeling, maintenance and operation of any structures and facilities, and in the conduct of all programs, services and training associated with services delivered under the Agreement (viii) all regulations and administrative rules established pursuant to the foregoing laws, (ix) all other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations, and (x) all federal laws governing operation of Community Mental Health Programs, including without limitation, all federal laws requiring reporting of Individual abuse. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the Agreement and required by law to be so incorporated. No federal funds may be used to provide Work in violation of 42 USC 14402. D. If the limitation amount speCified in this Agreement for Title XIX Clinic Services exceeds $100,000, Contractor shall provide the State of Oregon with written assurance that Contractor will comply with all applicable standards, orders, or requirements issued under Section 306 of the Clean Air Act (42 USC 1857 (h), the Federal Water Pollution Control Act as amended (commonly known as the Clean Water Act) including but not limited to Section 508 of the Clean Water Act (33 USC 1368) Executive Order 11738 and Environmental Protection Agency regulations (40 CFR Part 15) which prohibit the use under non-exempt Federal contracts, grants or loans of facilities included on the EPA List of Violating Facilities. Violations shall be reported to the OHA, HHS and the appropriate Regional Office of the Environmental Protection Agency. E. Contractor shall comply with Federal rules and statutes pertaining to the Addictions and Mental Health (AMH) and Social Security (formerly Title XX) Block Grant(s); including the Public Health Services Act, especially sections 1914 (b)(1-5), 1915 (c)(12), 1916 (b)(2) and Public Law 97-35. F. The individual signing on behalf of Contractor hereby certifies and swears under penalty of perjury that she/he is authorized to act on behalf of Contractor. G. The provisions of Deschutes County Code, Section 2.37.150 are incorporated herein by reference. 18. Hold Harmless. A To the fullest extent authorized by law Contractor shall defend (in the case of the state of Oregon and the Oregon Health Authority, subject to ORS Chapter 180), save, hold harmless and indemnify the County, the State of Oregon and the Oregon Health Authority their officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses of any nature resulting from or arising out of, or relating to the activities of Contractor or its officers, employees, contractors, or agents under this Agreement, including without limitation any claims that the work, the work product or any other tangible or intangible items delivered to County by PAGE 7 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 Contractor that may be the subject of protection under any state or federal intellectual property law or doctrine, or the County's use thereof, infringes any patent, copyright, trade secret, trademark, trade dress, mask work utility design or other proprietary right of any third party. B. Contractor shall have control of the defense and settlement of any claim that is subject to subparagraph a of this paragraph; however neither Contractor nor any attorney engaged by Contractor shall defend the claim in the name of Deschutes County or any department or agency thereof, nor purport to act as legal representative of the County or any of its departments or agencies without first receiving from the County's legal counsel, in a form and manner determined appropriate by the County's legal counsel, authority to act as legal counsel for the County, nor shall Contractor settle any claim on behalf of the Count without the approval of the County's legal counsel. C. To the extent permitted by Article XI, Section 10, of the Oregon Constitution and the Oregon Tort Claims Act, ORS 30.260 through 30.300, County shall defend, save, hold harmless and indemnify Contractor and its officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses of any nature resulting from or arising out of, or relating to the activities of County or its officers, employees, contractors, or agents under this Agreement. 19. Insurance. Prior to the effective date of this Agreement, Contractor shall obtain, at Contractor's expense, and maintain in effect all insurance requirements as speCified in Exhibit 2. 20. Settlement of Disputes. Differences between a Contractor and County, or between contractors, will be resolved when possible at appropriate management levels, followed by consultation between boards, if necessary. 21. Financial Audit. Contractor shall provide a copy of its financial review or financial audit conducted by a certified public accountant within ninety (90) days following the end of each fiscal year. 22. Assignment. Contractor shall not assign this Agreement without the prior written consent of County. 23. Renewal. This Agreement may be renewed, subject to the following conditions: (1) renewal will be based on the County Annual Implementation Plan approved by the OHA, and (2) renewal is subject to the availability of funding. 23. Contractor shall comply with provisions, requirements of funding source and Federal and State laws, statutes, rules, regulations, executive orders and policies. See Exhibit 4. 24. Reductions in Agreement Funding. A. Any funds spent by Contractor for purposes not authorized by this Agreement shall either be paid directly by the Contractor to the County or, if not so paid, at the discretion of County, shall be applied to future payments from County to the Contractor. Payments by County in excess of authorized amounts that have not been repaid by the Contractor within thirty (30) days after the Agreement's expiration or after notification by the County, whichever date is earlier, shall be deducted from future payments from County to the Contractor or may justify termination of the Agreement. B. In the event that a statutorily required operating license or letter of approval is suspended or not extended, County's obligation to provide reimbursement for services or program expenses hereunder will cease on the date of termination of this Agreement (whether in whole or in part) or the date of expiration or suspension of the license or letter of approval, whichever date is earlier. 25. Attorney Fees. In the event an action, suit or proceeding, including appeal there from, is brought for breach of any of the terms of this Agreement, or for any controversy arising out of this Agreement, each party shall be responsible for its own attorney's fees, expenses, costs and disbursements for said action, suit, proceeding or appeal. 26. Entire Agreement. This Agreement constitutes the entire Agreement between the parties on the subject matter hereof. There are no understandings, contracts, or representations, oral or written, not specified herein regarding this Agreement. PAGE 8 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013~364 27. Survival. The provisions of paragraphs 3 to 12, 15, 17 to 19, 21 to 24, shall survive the termination or expiration of this Agreement. DATED this __day of ________, 2013 COUNTY: Deschutes County Health Services BOARD OF COUNTY COMMISSIONERS OF DESCHUTES COUNTY, OREGON ALAN UNGER, Chair TAMMY BANEY, Vice Chair ATIEST: Recording Secretary ANTHONY DEBONE, Commissioner CONTRACTOR: Telecare Mental Health Services of Oregon, Inc. PAGE 9 OF 9 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013~364 EXHIBIT 1 DESCHUTES COUNTY SERVICES AGREEMENT STATEMENT OF WORK, COMPENSATION PAYMENT TERMS AND SCHEDULE Definitions: Adult Mental Health Initiative (AMHI): AMHI is a system reform project initiated by the Oregon Health Authority (OHA). The purpose of the initiative is to improve the system of community-based long term care and residential services for people who have been in the Oregon State Hospital. The proposal is to shift resources and authority from the State of Oregon to Mental Health Organizations and counties for the referral and management of individuals placed in state hospital and residential facilities. This would only include people involved in or at risk of the civil commitment process. Residential Treatment Services: For the purposes of this Agreement, Residential Treatment Services are behavioral health services delivered on a 24-hour basis to individuals eighteen (18) years of age or older with mental or emotional disorders who have been hospitalized, who are at immediate risk of hospitalization, who need continuing services to avoid hospitalization or who are a danger to themselves or others or who otherwise require continuing care to remain in the community. Residential Treatment Services includes services delivered to individuals who the County, in conjunction with the OHA has determined are unable to live independently without supervised intervention, training or support and are eligible for MHS 28 Services funded through this Agreement. Division of Medical Assistance Programs (DMAP): An office of the Oregon Health Authority responsible for coordinating Medical Assistance Programs, including the OHP Medicaid Demonstration and the Children'S Health Insurance Program (CHIP). DMAP writes and administers the state Medicaid rules for medical services, contracts with providers, maintains records of Individual eligibility and processes and pays DMAP providers. Extended Care Services: Non-OHP Medicaid rehabilitative services that are reimbursed on a fee for service basis. These services are billed with the use of specially designated Non-Oregon Health Plan (OHP) Medicaid Extended Care Services billing codes. Use of these codes requires prior authorization by the County and Central Oregon Health Board. Part A Funds: These funds are dispersed directly to Deschutes County by State of Oregon through Intergovernmental Contract for Financing of Community Mental Health Services. Part B Funds: These funds are awarded to Deschutes County by State of Oregon through Intergovernmental Contract for Financing of Community Mental Health Services as a limitation amount only. Funds are not dispersed directly to Deschutes County. The OHA's Division of Medical Assistance Programs (DMAP) disburses the award up to the limitation amount directly to the service provider on a fee-for-service basis. Personal Care Services: Services delivered in Residential Treatment Homes or Facilities that include but are not limited to the following: crisis stabilization, money and household management, supervision of daily living activities, provision of care for safety and well-being, administration and supervision of medication, provision and arrangement of routine transportation, behavior management, management of diet and physical health problems. 1. Contractor shall perform the following work: Service 1: Residential Treatment Home (RTH): A. The purpose of RTH services is to stabilize resident's psychiatric symptoms, improve independent living skills, and then discharge the resident into an appropriate and safe level of community services of less intensity as clinically appropriate. PAGE 1 OF 4 -EXHIBIT 1 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 B. Contractor shall provide 24-hour RTH services for up to ten (10) residents. Contractor shall provide RTH services described in the attached Service Description titled "Residential Treatment Services, Service ID code MHS 28, Exhibit 1A and in accordance with OAR 309-035-0250 through 309-035-0460, in homes at two locations in Deschutes County. Services shall include: 1. Non-Residential Adult Mental Health Services, Service ID Code MHS 20 B, Exhibit 1 B; 2. Residential Treatment Services, Service ID Code MHS 28, Exhibit 1-D; 3. Medicaid reimbursable service billings in accordance with the OHA Medicaid General Provider Rules 410-120-0000 through 410-120-1940; OHA Mental Health and Developmental Disability Services Medicaid Payment for Rehabilitative Mental Health Services Rule as listed in OAR 309-016-0600 through 309-016-0650; and Integrated Services and Supports Rule 309 032-1500 through 309-032-1565. 4. Contractor must enroll all Individuals served in Oregon State's Client Process Monitoring System (CPMS) database within twenty-four (24) hours of admission and disenroll within twenty-four (24) hours of discharge. 5. Residential Screening Process: The Contractor must jointly participate with the County in a screening process for all potential admissions to a RTH facility. Contractor understands that the County must also approve any Individual admitted to the facility. C. The Contractor must ensure the following at the Facility where RTH services are provided: 1. Currently have in place and maintain throughout the life of this Agreement, licensing as a Residential Treatment Home as defined in OAR 309-035-0250 through 309-035-0460. 2. Contractor must obtain and maintain any other licenses and/or certifications as necessary or required by law or administrative rule for a provider of RTH services and as an operator of the facility. This will include Contractor maintaining approval under OAR 309-012-0130 through 309-012-0220, "Certificates of Approval for Mental Health Services". 3. Contractor agrees to provide only those outpatient behavioral health services that are required for Contractor's role as a residential treatment provider. Contractor agrees to not utilize this certification to establish or provide any other outpatient services within Deschutes County unless expressly approved by County under separate agreement. D. Contractor shall provide RTH services to Individuals who meet the following criteria: 1. Be eighteen (18) years or older; and 2. Be referred by the Oregon Health Authority (OHA) Adult Mental Health Initiative (AMHI) and approved by County in collaboration with the program treating referral hospital, responsible Community Mental Health Program (CMHP) and/or the Mental Health Organization (if enrolled) responsible for the Individual. (See Exhibit 1 E, "Referrals"); and 3. Have an Axis I Diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders; and 4. Be currently approved for Long Term Psychiatric Care by AMHI; or 5. Be referred directly by Deschutes County in accordance with County Bed Referral procedures (Exhibit 1 E); or 6. Be a Medicaid eUgible Individual in a benefit category that allows for payments for Medicaid Rehabilitative Services. 2. County Services. County shall provide Contractor, at County's expense, with material and services described as follows: 1. County will maintain primary responsibility for screening and approval of admissions to the residential treatment facilities and will provide Residential Specialist staff to participate in this process. Screenings will be conducted in coordination with Contractor's RTH staff, however, any resident accepted for admission to the facility must also be approved by the County for placement. Residential Specialist staff will also provide regular outreach and coordination with Contractor's RTH staff. 2. County agrees to provide a letter of support to Contractor as part of certification application outlined in 1 (B)(2) for Contractor to operate as an Outpatient Mental Health Provider within Deschutes County and to provide the required monitoring and oversight in coordination with Addictions and Mental Health Division. 3. County agrees to provide all other out-patient behavioral health services including but not limited to: medication management, individual and group therapy and supported employment services. PAGE 2 OF 4 -EXHIBIT 1 -PERSONAL SERVICES CONTRACT No. 2013-364 ------------------ 3. Consideration. Subject to availability of funds, Contractor will receive payment for providing the services described in Exhibit 1, Paragraph 1. A. Contractor shall bill DMAP in accordance with procedures and forms prescribed by OHA for all services funded under Part B dollars. Contractor agrees that payment for these services shall be DMAP's responsibility and not County's responsibility. Contractor shall not invoice or expect payment from County for services billed to DMAP under this subsection. i) All Extended Care Services reimbursable service billings shall be in accordance with the OHA Medicaid General Provider Rules 410-120-0000 through 410-120-1940 and MHS Mental Health and Developmental Disability Services Medicaid Payment for Rehabilitative Mental Health Services Rule as listed in OAR 309-016-0600 through 309-016-0685. ii) Contractor shall bill all Personal Care Services in accordance with forms and procedures prescribed byOHA. iii) Contractor agrees to complete, monitor and obtain all prior authorizations as needed for Extended Care Service and Personal Care Service billing submissions. B. County agrees to pay to Contractor, all "Part A" funds received by County which are allocated by OHA for services provided by Contractor as described in this Exhibit. i) Contractor agrees to invoice County on a monthly basis for Part A payments that are approved by the OHA as part of Contractor's budget and paid to the County by amendment to OHA State Contract. County agrees to make approved payments to Contractor within thirty (30) days of receipt of invoice and receipt of funds from the OHA. ii) Contractor agrees to complete and submit all documentation of expenditures for all Part A funds as required by OHA and the County and to comply with all reqUirements of the Service Description in which funding is allocated. C. Funding for operation of the facilities will be in accordance with a budget submitted by Contractor to OHA and County and approved by OHA and County. D. Contractor shall be entitled to reimbursement for travel expenses 0 YES ~NO [Check one] 4. The maximum compensation. A. The maximum consideration under this Agreement shall be $592,500. This maximum compensation is calculated for payments provided through December 31,2013. Payments beyond December 31,2013 will be agreed upon through an amendment, Signed and executed by both Parties. County will pay Contractor up to the total maximum amount allocated by Oregon Health Authority for Contractor services to the County under the contract between OHA and County. All funds allocated to County as "Part B" payments will be paid directly to the Contractor by DMAP on the County's behalf. All funds allocated to County for services provided by the Contractor as "Part A" payments, will be paid to the Contractor directly by the County. All funds will be paid in accordance with a budget that is approved by Oregon Health Authority. B. All funds awarded to Contractor under this Agreement are subject to Oregon Health Authority monitoring and adjustment. All adjustments in funds awarded will be made by amendment to the contract between OHA and County. Oregon Health Authority will monitor and adjust funds awarded throughout the term of this Agreement at Oregon Health Authority discretion. C. Recovery of Overpayment: All payments made to Contractor under this Agreement are subject to recovery by OHA and/or the County in accordance with OAR 410-120-1397 Recovery of Overpayments to Providers --Recoupments and Refunds and Service Element Descriptions for MHS 28, MHS 20, and MHS 37 funds: i. If a federal audit of the work rendered by Contractor under this Agreement results in a refund to or disallowance by the federal government of funds paid to Contractor under this Agreement, Oregon Health Authority and/or County may recover from Contractor the amount of the refund or disallowance and any applicable Oregon Health Authority matching funds. ii. If Contractor expends funds paid to Contractor under this Agreement for purposes not authorized by this Agreement, Oregon Health Authority and/or County may recover the amount of the unauthorized expenditure from Contractor. PAGE 3 OF 4 -EXHIBIT 1 -PERSONAL SERVICES CONTRACT No. 2013-364 I iii. If billings under this Agreement result in payments to Contractor to which Contractor is not entitled, Oregon Health Authority and/or County, after giving written notification to Contractor, may withhold from payments due to Contractor such amounts, over such periods of time as are necessary to recover the amount of overpayment. D. Contractor may also receive funding for Start-up Special Projects as outlined in Service 10 Code MHS 37, Exhibit 1-C. 5. Schedule of Performance or Delivery. a. County's obligation to pay depends upon Contractor's delivery or performance in accordance with the schedule listed in Exhibit 1, Paragraph 1. b. County will only pay for completed work that conforms to the terms of the Agreement. 6. Renewal. This Agreement may be renewed as outlined in this Agreement and subject to the following conditions: a. Renewal will be based on the County Annual Implementation Plan approved by the OHA. b. Renewal is subject to the availability of funding. 7. Modification of Exhibit 1-A through 1-0, State Requirements for Behavioral Health Subcontract In the event the State of Oregon modifies the terms of SE 28, 20, or 37, it is understood and agreed that this Agreement will also be revised accordingly. Authority to change this Exhibit to comply fully with Deschutes County's Contract with OHA shall rest with the Director of Contractor and the Director of County. Both parties must agree for the Exhibit to be modified. PAGE 4 OF 4 -ExHIBIT 1 -PERSONAL SERVICES CONTRACT No. 2013-364 EXHIBIT 1-A Service Name: RESIDENTIAL TREATMENT SERVICES Service ID Code: MHS 28 I. Service Description Residential Treatment Services (MHS 28) are: A. Services delivered on a 24-hour basis to individuals 18 years of age or older with mental or emotional disorders who have been hospitalized or are at immediate risk of hospitalization, who need continuing services to avoid hospitalization or who are a danger to themselves or others or who otherwise require continuing care to remain in the community; and B. Services delivered to individuals who the County. in conjunction with the Oregon Health Authority (OHA) determines are unable to live independently without supervised intervention, training or support. The specific MHS 28 Services delivered to an individual are determined based upon an individualized assessment of treatment needs and development of plan of care that are intended to promote the well being, health and recovery of the individual through the availability of a wide-range of residential service options. MHS 28 Services delivered to an individual are determined based upon an individualized assessment of treatment needs and development of plan of care that are intended to promote the well being, health and recovery of the individual through the availability of a wide range of residential service options. MHS 28 Services delivered in Residential Treatment Facilities (as defined in OAR 309-035-0100 through 309 035-0190) (RTH) or Residential Treatment Homes (as defined in OAR 309-035-0250 through 309-035-0460) (RTH), or another licensed setting approved by OHA include, but are not limited to, the following: A. Crisis stabilization services, such as acceSSing psychiatric, medical, or qualified professional intervention to protect the health and safety of the individual and others; B. Timely, appropriate access to crisis intervention to prevent or reduce acute, emotional distress, which might necessitate psychiatric hospitalization; C. Management of personal money and expenses; D. Supervision of daily living activities and life skills such as training with nutritional wellness, personal hygiene, clothing care and grooming, communication with social skills, health care, household management and using community resources; E. Provision of care including assumption of a responsibility for the safety and well-being of the individual; F. Administration and supervision of prescribed and non-prescribed medication; G. Provision or arrangement of routine and emergency transportation; H. Management of aggressive or self-destructive behavior; I. Management of a diet, prescribed by a physician, requiring extra effort or expense in preparation of food; and J. Management of physical or health problems, including. but not limited to, seizures or incontinency. Financial assistance is dependent upon an individual meeting defined criteria, established by the Oregon Health Authority (OHA) and posted on the OHA, Addictions and Mental Health (AMH) website. OHA and its designees have the authority to review Clinical records and have direct contact with individuals. The County and any providers must notify individuals in writing within five state business days of a determination on admission, as PAGE 1 OF 4 -EXHIBIT 1-A -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 defined by OHA policy, posted on the OHA AMH website located at: http://www.oregon.gov/oha/amh/Pagesitools-providers.aspx. II. Performance Requirements A provider of MHS 28 services shall give first priority in admission to referrals from individuals transitioning from the State Hospitals, and referrals of individuals on the State Hospital wait list. A Provider of MHS 28 Services funded through this Agreement must deliver the Services in a facility licensed as a Residential Treatment Facility or Secured Residential Treatment Facility under OAR 309-035-0100 through 309-035-0190 or as a Residential Treatment Home under OAR 309-035-0250 through 309-035-0460, as such rules may be revised from time to time. III. Special Reporting Requirements county must complete and deliver to OHA the form as prescribed by OHA for any individual receiving MHS 28 Services funded through this Agreement when the individual is transferred to another residence or facility operated by the Provider, the individual is transferred to another Provider of MHS 28 Services, MHS 28 Services to the individual end or the payment rate for the individual changes. An individual's payment rate may only be changed after consultation with and approval by OHA and only if the MHS 28 Services for that individual are funded from the Residential Limitation (as defined below). If County has authorized or anticipates authorizing delivery of MHS 28 Services to an individual and wishes to reserve MHS 28 service capacity for that individual for a short period of time when the individual is not actually receiving the services, County must submit a written Reserved Service Capacity Payment (RSCP) Request and Contract Amendment Request to OHA under OAR 309-011-0105 through 309-011-0115. If OHA approves the RSCP and Contract Amendment Request, OHA and County shall execute an amendment to the contract between OHA and County to reduce Residential Limitation, Part B, and add funds necessary to make the approved payments to reserve the service capacity to the Part A Award. OHA shall have no obligation to make the payments unless and until the contract between OHA and County has been so amended. All individuals receiving Services with funds provided under this Agreement must be enrolled at that client's record maintained in either: a. the Client Process Monitoring System (CPMS) as speCified in OHA's manual located at: http://www.oregon.gov/OHNamh/training/cpms/idex.shtml, and as it may be revised from time to time; or b. the Measures and Outcome Tracking System (MOTS) as specified in OHA's MOTS manual located at: http://www.oregon.gov/OHNamh/pages/compass/electronic-data-capture.aspx, and as it may be revised from time to time. Over the next two (2) years, AMH will be clOSing the CPMS system and replacing it with the MOTS system. Providers, including Contractor will be notified by AMH of the change. IV. Financial Assistance Calculation, Disbursement and Settlement Procedures OHA provides financial assistance for MHS 28 Services in two different ways. Certain funds (the "Part A Award") are calculated, disbursed and settled as set forth in Section IV (A) below. The Part A Award is set forth in the contract between OHA and County on MHS 28 lines that contain an "An in column one. Other funds (the "Residential Limitation") are not calculated, disbursed or settled under this Agreement. These funds are set forth in the contract between OHA and County on MHS 28 lines that contain a "B" in column one and are paid as described in Section IV (B) below. Part B Limitation: The provider of the service needs to be enrolled as a Medicaid Provider and follow the procedures for billing OHA for Medicaid mental health services outlined in the Medicaid provider manual. OHA calculates the rates and the claims are processed through OHA' Medicaid Management Information System (MMIS). OHA calculates the Part B limitation and OHA' Division of Medical Assistance Programs (DMAP) disburses the payment directly to service providers on a fee-for-service basis. OHA sets procedures and rates for the Limitation. Rates are available on the OHA website located at http://www.oregon.gov/oha/amh/pages/tools-providers.aspX#m. PAGE 2 OF 4 -EXHIBIT 1-A -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 OHA will provide notice to County in timely manner if there is a change in rates. All Medicaid reimbursable service billings shall be in accordance with the OHA Mental Health and Developmental Disability Services Medicaid Payment for Rehabilitative Mental Health Services Rule as listed in OAR 309-016-0600 through 309 016-0755 and the OHA AMH Mental Health and Chemical Dependency Medicaid Provider Manual available on the OHA website located at http://www.oregon.gov/ohalamh/publications/other/provider2009manual.pdf. A. The Part A Award will be calculated, disbursed and settled as follows: 1. Calculation of Financial Assistance. OHA will provide financial assistance for MHS 28 Services identified in a particular line of the contract between OHA and County with an UN in column one from funds identified on that line in an amount equal to the rate set forth in the special condition identified in that line of the contract between OHA and County, multiplied by the number of units of MHS 28 Services delivered under that line of the contract between OHA and County during the period specified in that line, subject to the following: i. Total OHA payment for MHS 28 Services delivered under a particular line in the contract between OHA and County containing an "A" in column one shall not exceed the total funds awarded for MHS 28 Services as specified in that line of the contract between OHA and County; ii. OHA is not obligated to provide financial assistance for any MHS 28 Services that are not properly reported in accordance with section 2., "Special Reporting Requirements" above or as required in an applicable Specialized Service Requirement by the date Sixty (60) days after the earlier of termination or expiration of this Agreement, termination of OHA' obligation to provide financial assistance for MHS 28 Services, or termination of County's obligation to include the Program Area, in which MHS 28 Services fall, in its Community Mental Health Program (CMHP); and iii. OHA will reduce the financial assistance for MHS 28 Services delivered under a particular line of the contract between OHA and County containing an "A" in column one by the amount received by a Provider of MHS 28 services, as payment of a portion of the cost of the services from an individual receiving such services. 2. Disbursement of Financial Assistance. Unless a different disbursement method is specified in that line of the contract between OHA and County, OHA will disburse funds awarded for MHS 28 Services identified in a particular line of the contract between OHA and County with an "A" in column one, to County in substantially equal monthly allotments during the period specified in that line of the contract between OHA and County, subject to the following: a. OHA may, after thirty (30) days (unless parties agreed otherwise) written notice to County, reduce the monthly allotments based on under used allotments identified in accordance with section 3.2 "Special Reporting Requirements" above or applicable Special Terms and Conditions. b. OHA may, upon written request of County, adjust monthly allotments. c. Upon amendment to the contract between OHA and County, OHA shall adjust monthly allotments as necessary, to reflect changes in the funds awarded for MHS 28 Services on that line of the contract between OHA and County. 3. Agreement Settlement. Agreement Settlement will reconcile any discrepancies that may have occurred during the term of this Agreement between actual OHA disbursements of funds awarded for MHS 28 Services under a particular line of the contract between OHA and County containing an "A" in column one and amounts due for such services provided by County based on the rate set forth in the special condition identified in that line of the contract between OHA and County. For purposes of this section, amounts due to County is determined by the actual amount of services delivered under that line of the contract between OHA and County during the period specified in that line of the contract between OHA and County, as properly reported in accordance with section 3. "Special Reporting Requirements" above or as required in an applicable Specialized Service Requirement. PAGE 3 OF 4 -EXHIBIT 1-A -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 The settlement process will not apply to funds awarded for an approved Reserved Service Capacity Payment. B. Residential Limitation. The Residential Limitation, Part B is disbursed by OHA directly to service providers based on monthly rates authorized by County after consultation with OHA, subject to the following: 1. All payment rates authorized by County under this Section IV (B) for delivery of MHS 28 Services must meet the following requirements: i. The rates must be reasonable under the facts and circumstances in existence at the time each rate is set, including but not limited to the state of the market for MHS 28 Services in the geographic area in which the services will be delivered and the needs of the particular individual receiving services. 2. County shall not authorize, in aggregate under this Section IV (B), financial assistance for MHS 28 Services in excess of the Residential Limitation. Total aggregate financial assistance means the total of all financial assistance authorized before reducing payments to account for client resources received by the provider from a client, or another on behalf of the client, in support of client care and services provided; 3. The monthly rate will be prorated for any month in which the individual is not served for a portion of the month; 4. Financial assistance will be reduced (offset) by the amount of client resources received by the provider from the client or client's health insurance in support of client care and services provided; 5. The Residential Limitation is included in this Agreement for budgetary purposes. If OHA anticipates that payments for MHS 28 Services authorized by County under this Section IV (B) will exceed the amount of the Residential Limitation, OHA may unilaterally reduce the award of funds, as set forth in the contract between OHA and County, for any other MHS Service or Services to the extent of the State of Oregon's general fund portion of the anticipated Residential Limitation shortfall. OHA and County shall execute an appropriate amendment to the contract between OHA and County to reflect the reduction of the Part A Award and the increase in the Residential Limitation; and 6. OHA is not obligated to provide financial assistance for any MHS 28 Services that are not properly reported in accordance with section 3, "Specialized Reporting Requirements" above or as required in an applicable Specialized Service Requirement by the date Sixty (60) days after the earlier of termination or expiration of this Agreement, termination of OHA' obligation to provide financial assistance for MHS 28 Services or termination of County's obligation to include the Program Area, in which MHS 28 Services fall, in its CMHP. PAGE 4 OF 4 -EXHIBIT 1-A -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 EXHIBIT 1-B Service Name: NON-RESIDENTIAL MENTAL HEALTH SERVICES FOR ADULTS (GENERAL) Service ID Code: MHS 20 I. Service Description Non-Residential Mental Health Services For Adults (General) (MHS 20) are mental health services delivered to persons diagnosed with serious mental health illness, or other mental or emotional disturbance posing a danger to the health and safety of themselves or others. Non-Residential Mental Health Services for Adults (General) shall include one or more of the following: A. Supported Housing service payment; B. Rental Assistance; C. Non-Medically approved services required by PSRB (Part C); and D. Other services as needed for individuals at the sole discretion of AMH; II. Performance Requirements Providers of MHS 20 shall provide coordination of care services for county of responsibility residents in residential treatment programs, which include extended care managed services, regardless of the location. The coordination of care shall include participation in the residential provider's treatment planning process and in planning for the individual's transition to outpatient services. Providers of MHS 20 Services funded through this Agreement must: A. Comply with OAR 309-032-1500 through 309-032-1565, as such rules may be revised from time to time; B. Maintain a Certificate of Approval, for the delivery of clinical services, in accordance with OAR 309-012 0130 through OAR 309-012-0220, as such rules may be revised from time to time; and C. Investigate and report allegations of abuse regarding served individuals and provide protective services to those individuals to prevent further abuse. The investigation, reporting and protective services must be completed in compliance with ORS 430.735 through 430.765 and OAR 407-045-0000 through 407 045-0980, as such statutes and rules may be revised from time to time. III. Special Reporting Requirements Providers of MHS 20 Services funded through this Agreement must: A. Submit information and data on abuse reports, investigations and protective services involving individuals to whom the Provider provides MHS 20 Services, as such information and data is reasonably requested by the Oregon Health Authority (OHA) in order to fully understand allegations and reports of abuse, the resulting investigations and protective services and any corrective actions. B. All individuals receiving MHS 20 Services with funds provided under this Agreement must be enrolled and that client's record maintained in either: 1. the Client Process Monitoring System (CPMS) as specified in OHA's CPMS manual located at: http://www.oregon.gov/OHNamh/training/cpms/index.shtml, and as it may be revised from time to time; or 2. the Measures and Outcome Tracing System (MOTS) as specified in OHA's MOTS manual located at http://www.oregon.gov/OHNamh/pages/compass/electronic-data-capture.aspx, and as it may be revised from time to time. PAGE 1 OF 3 --EXHIBIT 1-B -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2013-364 Over the next two (2) years, AMH will be closing the CPMS system and replacing it with the MOTS system. Providers, including Contract will be notified by AMH of the change. IV. Financial Assistance Calculation, Disbursement & Settlement Procedures OHA provides financial assistance for MHS 20 Services in three different ways, through Part A and Part 8 rLimitation") Awards, and Part C awards. The Award is set in the contract between OHA and County on MHS 20 lines in column one (1) that contain an uN for Part A or "8" for Part 8 Award or "C" for Part C Award. The Part 8 award is not calculated, disbursed or settled under this Agreement, but is included for budgetary purposes. The provider of the service needs to be enrolled as a Medicaid Provider and follow the procedures for billing the OHA for Medicaid mental health services outlined in the Chemical Dependency Medicaid Provider Manual. OHA calculates the rates and the claims are processed through the OHA's Medicaid Management Information System (MMIS). OHA calculates the Part 8 limitation and OHA' Division of Medical Assistance Programs (DMAP) disburses the payment directly to service providers on a fee-for-service basis. Rates are available on the OHA website located at http://www.oregon.gov/oha/amh/pagesltoois-providers.aspX#m. OHA will provide notice to Contractor in timely manner if there is a change in rates. All Medicaid reimbursable service billings shall be in accordance with the OHA Mental Health and Developmental Disability Services Medicaid Payment for Rehabilitative Mental Health Services Rule as listed in OAR 309-016-0600 through 309-016-0755 and the OHA AMH Mental Health and Chemical Dependency Medicaid Provider Manual available on the OHA website located at http://www.oregon.gov/oha/amh/publications/other/provider2009manual.pdf. The Part A Award financial assistance will be calculated, disbursed and settled as follows: A. Calculation of Financial Assistance: The Part A Award for MHS 20 Services is intended to be general financial assistance to County for MHS 20 Services. Accordingly, OHA will not track delivery of MHS 20 Services or service capacity on a per unit basis so long as County offers and delivers MHS 20 Services as part of its CMHP. 1. Total OHA financial assistance for MHS 20 Services under a particular line of the contract between OHA and County shall not exceed the total funds awarded for MHS 20 Services as specified on that line. 2. OHA is not obligated to provide financial assistance for any MHS 20 Services delivered to individuals that are not property reported in accordance with section 3., "Special Reporting Requirements" above or as required by this Service Description or an applicable Specialized Service Requirement) by the date sixty (60) days after the earlier of termination of this Agreement, termination of OHA's obligation to provide financial assistance for MHS 20 Services, or termination of County's obligation to include the Program Area, in which MHS 20 Services fall, in its CMHP. 8. Disbursement of financial assistance: Unless a different disbursement method is specified in that line of the contract between OHA and County, OHA will disburse the Part A Award for MHS 20 Services identified in a particular line of the contract between OHA and County to County in substantially equal monthly allotments during the period speCified in that line of the contract between OHA and County, subject to the following: 1. OHA may, upon written request of County, adjust monthly allotments. 2. Upon amendment to the contract between OHA and County, OHA shall adjust monthly allotments as necessary, to reflect changes in the funds awarded for MHS 20 Services on that line of the contract between OHA and County. 3. OHA may reduce the monthly allocation when the county is identified by the Addictions and Mental Health Division (AMH) as the County of Responsibility of a patient at the State Hospital and the patient exceeds the length of stay authorized by OHA by more than 30 days. The reduction of the monthly allocation will be based on the following table: C. The Part C Award financial assistance will be disbursed as follows: PAGE 2 OF 3 -EXHIBIT 1-8 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2013-364 (1) Unless a different disbursement method is specified in that line of Exhibit D-1 in the Contract between OHA and County, OHA will disburse the Part C Award for MHS 20 Services identified in a particular line of the Contract between OHA and County to County per receipt and approval of written invoice, with attached copy of the bill or receipt of the item or service and a copy of the POC and CCO refusal of payment, in the monthly allotments during the period specified in that line of the contract between OHA and County. Part C Awards for PSRB non-medically approved services is for the time period as shown only and does not carry forward into following years funding. D. Agreement Settlement: Agreement Settlement will be used to confirm the offer and delivery of MHS 20 Services by County as part of its CMHP based on data properly reported in accordance with section 3" "Special Reporting Requirements" above or as required in an applicable Specialized Service Requirement. The settlement process will not apply to funds awarded for Rent Subsidy payments. 0-30 0% i 31-60 25% 61-90 50% 91 -120 75% 121 and over 100% PAGE 3 OF 3 -EXHIBIT 1-B DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 I EXHIBIT 1-C Service Name: MHS SPECIAL PROJECTS Service ID Code: MHS 37 I. Service Description MHS Special Projects (MHS 37) are mental health services within the scope of ORS 430.630 delivered on a demonstration or emergency basis for a specified period of time. Each project is described in a separate exhibit to this MHS 37 Service Description. When the contract between the State and County contains a line awarding funds for MHS 37 Services, that line will contain a special condition specifying the exhibit to this MHS 37 Service description that describes the project for which the funds are awarded. The specific MHS 37 Services to be provided under this Agreement are described in exhibits, if any, to this MHS 37 Service Description, which exhibits are incorporated herein by this reference. II. Performance Requirements Providers of MHS 37 Services funded through this Agreement with Medicaid dollars must comply with OAR 309 016-0000 through 309-016-0755. See exhibits, if any, to this MHS 37 Service Description. III. Special Reporting Requirements See exhibits, if any, to this MHS 37 Service Description. IV. Payment Procedures See exhibits, if any, to this MHS 37 Service Description. Even if the contract between the State and County awards funds for MHS 37 Services, the Oregon Health Authority (OHA) shall have no obligation to provide financial assistance for any MHS 37 Services under this Agreement (even if funds therefore are disbursed to County) unless a special project description is attached to this Service Description as an exhibit. PAGE 1 OF 1 -EXHIBIT 1-C DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 EXHIBIT 1-D USE OF COUNTY BEDS IN RESIDENTIAL TREATMENT HOMES Use of the Six "County Beds" in Residential Treatment Homes in Deschutes County Purpose of this Agreement: To outline the use of County beds in State-supported residential programs in the residential treatment homes in Deschutes County. Funding: • OHA will make the service payment to the residential provider for any resident in a County bed, regardless of the length of stay even if less than thirty (30) days. The resident does not need to be Medicaid eligible for placement, but all eligible residents will be enrolled in Medicaid. Payment will be through Medicaid system for approved individuals. • If the Individual does not have income, County will also make a request to OHA for payment of R&B and PIF. Types of Individuals the County may place in a County Bed may include, but not be limited to (examples): • A discharge from a local acute care unit who is a placement problem and needs additional stabilization; • An Individual in the community who is deteriorating or at risk of commitment, but not yet meeting commitment criteria; • An Individual who may be new to the community, has a history of mental illness and is in an unstable living situation; • Relief for a family who is caring for difficult an Individual in the home. A 2-3 month placement may help the family to continue as the primary care provider; • An Individual on probation, in and out of jail due to a mental illness related infraction and needing longer term stabilization; • Post-commitment, an Individual who need longer stabilization but is not necessarily eligible for a state hospital level of care and who has not qualified for AMHI; and • An Individual in the state hospital or the community who needs residential placement but has not traditionally been eligible due to lack of Medicaid eligibility. Length of stay • While some Individuals may need longer or shorter term placement, the goal would be to use this as transitional stabilization with a typical length of stay 30-90 days. Criteria General criteria -does not need to meet all for placement • Major mental illness as primary diagnosis. May also have dual diagnosis of substance abuse/dependence, a developmental disability and/or medical issues. • Must have a need for treatment for stabilization. A need for housing only would not meet the criteria for residential placement in a County bed. • Difficult to manage in the community and likely involved with other systems. • Recent or impending crisis. • Does not need acute care stabilization. • Individual agrees to remain clean and sober. • I ndividual agrees to placement for a minimum of thirty (30) days • Individual would typically be voluntary, except possibly for some Individuals under civil commitment. Referral Process • All referrals will be made from within Deschutes County to a designated DCHS staff person. If we are unable to fill all Deschutes County beds, DCHS will consider an AMHI referral to fill the bed. If this occurs, the next AMHI discharge will be converted back to a County bed to maintain 6-bed capacity within the system. PAGE 1 OF 2 -EXHIBIT 1-D -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 • A review team comprised of supervisory and housing staff will review referrals, prioritize between multiple referrals based on level of need, and determine appropriateness for placement. • The designated team member will coordinate with the residential program for final review and placement approval. Treatment needs from facility: • Ability to manage multiple issues in addition to mental illness (primarily substance abuse, developmental disabilities and medical issues). • Provide an environment that is inviting especially to a younger population. Note: we would anticipate that young males may have a particular need for this placement PAGE 2 OF 2 EXHIBIT 1-D -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 EXHIBIT 2 DESCHUTES COUNTY SERVICES AGREEMENT Agreement No. 2013-364 INSURANCE REQUIREMENTS Contractor shall at all times maintain in force at Contractor's expense, each insurance noted below. Insurance coverage must apply on a primary or non-contributory basis. All insurance pOliCies, except Professional Liability, shall be written on an occurrence basis and be in effect for the term of this Agreement. Policies written on a "claims made" basis must be approved and authorized by Deschutes County. Contractor Name: Telecare Mental Health Services of Oregon Inc. Workers Compensation insurance in compliance with ORS 656.017, requiring Contractor and all subcontractors to provide workers' compensation coverage for all subject workers, or provide certification of exempt status. Worker's Compensation Insurance to cover claims made under Worker's Compensation, disability benefit or any other employee benefit laws, including statutory limits in any state of operation with coverage B Employer's Liability coverage all at the statutory limits. In the absence of statutory limits the limits of said Employers liability coverage shall not be less than $1,000,000 each accident, disease and each employee. This insurance must be endorsed with a waiver of subrogation endorsement, waiving the insured's right of subrogation against County. Professional Liability insurance with an occurrence combined single limit of not less than: Per Occurrence limit Annual Aggregate limit o $1,00,000 [8] $2,000,000 [8] $2,000,000 0 $3,000,000 o $3,000,000 0 $5,000,000 Professional Liability insurance covers damages caused by error, omiSSion, or negligent acts related to profeSSional services provided under this Agreement. The policy must provide extended reporting period coverage, sometimes referred to as "tail coverage" for claims made within two years after this Agreement is completed. [8] Required bv County o Not required bv County (one box must be checked) Commercial General Liability insurance with a combined single limit of not less than: Per Single Claimant and Incident All Claimants Arising from Single Incident o $1,000,000 [8] $2,000,000 [8] $2,000,000 0 $3,000,000 o $3,000,000 0 $5,000,000 Commercial General Liability insurance includes coverage for personal injury, bodily injury, advertiSing injury, property damage, premises, operations, products, completed operations and contractual liability. The insurance coverages provided for herein must be endorsed as primary and non-contributory to any insurance of County, its officers, employees, or agents. Each such policy obtained by Contractor shall provide that the insurer shall defend any suit against the named insured and the additional insureds, their officers, agents, or employees, even if such suit is frivolous or fraudulent. Such insurance shall provide County with the right, but not the obligation, to engage its own attorney for the purpose of defending any legal action against County, its officers, agents, or employees, and that Contractor shall indemnify County for costs and expenses, including reasonable attorneys' fees, incurred or arising out of the defense of such action. The policy shall be endorsed to name, Deschutes County, its officers, agents, employees and volunteers as an additional insured. The additional insured endorsement shall not include declarations that reduce any per occurrence or aggregate insurance limit. The contractor shall provide additional coverage based on any outstanding claim(s) made against policy limits to ensure that minimum insurance limits required by the County are maintained. Construction contracts may include aggregate limits that apply on a "per location" or "per project" basis. The additional insurance protection shall extend equal protection to County as to Contractor or subcontractors and shall not be limited to vicarious liability only or any similar limitation. To the extent any aspect of this Paragraph shall be deemed unenforceable, then the additional insurance protection to County shall be narrowed to the maximum amount of protection allowed by law. [8] Required by County o Not required by County (one box must be checked) PAGE 1 OF 2 -EXHIBIT 2 -PERSONAL SERVICE CONTRACT No. 2013-364 Automobile Liability insurance with a combined single limit of not less than: Per Occurrence o $500,000 o $1,000,000 o $2,000,000 Automobile Liability insurance coverage for bodily injury and property damage resulting from operation of a motor vehicle. Commercial Automobile Liability Insurance shall provide coverage for any motor vehicle (symbol 1 on some insurance certificates) driven by or on behalf of Contractor during the course of providing services under this Contract. Commercial Automobile Liability is required for contractors that own business vehicles registered to the business. Examples include: plumbers, electricians or construction contractors. An Example of an acceptable personal automobile policy is a contractor who is a sole proprietor that does not own vehicles registered to the business. o Re uired b Coun x Not re uired b Count one box must be checked Additional Requirements. Contractor shall pay all deductibles and self-insured retentions. A cross-liability clause or separation of insured's condition must be included in all commercial general liability policies required by this Agreement. Contractors coverage will be primary in the event of loss. Certificate of Insurance Required. Contractor shall furnish a current Certificate of Insurance to the County with the signed Agreement. The Contractor shall notify County in writing at least thirty (30) days in advance of any cancellation, termination, material change, or reduction of limits of the insurance coverage. The Certificate shall also state the deductible or, if applicable, the self-insured retention level. Contractor shall be responsible for any deductible or self-insured retention. If requested, complete copies of insurance policies shall be provided to the County. Date £l/~~ \~ PAGE 2 OF 2 -EXHIBIT 2 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 Exhibit 3 Disclosure of Protected Health Information 1. Purpose. The purpose of this exhibit is to set forth the terms and conditions of disclosure of ·"protected health information" (as defined in Section 2.1 of this exhibit) between Contractor and COUNTY. It is the intent of COUNTY and Contractor that this exhibit will meet the requirements of 45 CFR § 164.504(e) of the privacy regulations and 45 CFR § 164.314(a) of the security regulations promulgated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (collectively the "HIPAA Regulations"). 2. Use And Disclosure Of PHI. 2.1 Definitions. For purposes of this exhibit, the term "protected health information" (PHI) means Individually Identifiable Health Information transmitted or maintained in any form or medium. "Individually Identifiable Health Information" is information, including demographic information, that: (a) relates to (i) the past, present or future physical or mental health or condition of an individual person, (ii) the provision of health care to an individual person, or (iii) the past, present or future payment for the provision of health care to an individual person; and (b) identifies that person (or with respect to which there is a reasonable basis to believe the information can be used to identify the person). Terms used by but not otherwise defined in this exhibit shall have the same meaning as those in 45 CFR Parts 160, 162, and 164. 2.2 Security and Confidentiality. If Contractor discloses any PHI to COUNTY, or if COUNTY creates or receives any PHI on behalf of Contractor, COUNTY will maintain the security and confidentiality of such PHI in County's possession as is required by the HIPAA Regulations. Contractor shall maintain the security and confidentiality of any PHI received by Contractor. 2.3 Use and Disclosure. Neither Contractor nor COUNTY not use or disclose PHI except as permitted by this exhibit or other parts of this Agreement, or as required by law. 2.4 Disclosure Procedure. Unless such disclosure is required by law, neither COUNTY nor Contractor may disclose PHI unless: (a) the disclosing party first obtains reasonable assurances from the person to whom the PHI is disclosed that the PHI will be held confidentially and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and (b) the person notifies the disclosing party of any instances of which the person is aware of breaches of confidentiality of the PHI. 3. Other Obligations. 3.1 Safeguards. COUNTY and Contractor will use appropriate safeguards to prevent use or disclosure of PHI otherwise than as permitted by this exhibit. 3.2 Reports. COUNTY will report to Contractor any use or disclosure of PHI by COUNTY or its Workforce not provided for by this exhibit of which COUNTY becomes aware. Contractor will report to COUNTY any use or disclosure of PHI by Contractor or its officers, employees or agents not provided for by this exhibit of which Contractor becomes aware. Agents. COUNTY will ensure that any agents, including subcontractors, to whom COUNTY provides PHI received from Contractor (or created or received by COUNTY on behalf of Contractor) agree to the same restrictions and conditions that apply to COUNTY with respect to such PHI. Contractor will ensure that any agents, including subcontractors, to whom Contractor provides PHI received from COUNTY (or created or received by Contractor on behalf of COUNTY) agree to the same restrictions and conditions that apply to Contractor with respect to such PHI. PAGE 1 OF 2 -EXHIBIT 3 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 3.3 Availability. COUNTY and Contractor shall make PHI in either's possession available to the individual who is the subject of the PHI as required by the HIPAA Regulations. 3.4 Amendment. COUNTY and Contractor shall make available PHI in its or their possession for amendment of the PHI by the person identified in the PHI and incorporate any such amendments in accordance with the HIPAA Regulations. 3.5 Access. If COUNTY has PHI in a designated record set, COUNTY wi" provide Contractor, upon Contractor's reasonable request, access for inspection of County's books, records, pOlicies, practices and procedures concerning the use and disclosure of PHI for purposes of aSSisting Contractor with its obligations for record keeping and compliance with complaint investigations and compliance reviews as required by the HIPAA Regulations. If Contractor has PHI in a designated record set, Contractor will provide COUNTY, upon COUNTY'S reasonable request, access for inspection of Contractor's books, records, policies, practices and procedures concerning the use and disclosure of PHI for purposes of assisting COUNTY with its obligations for record keeping and compliance with complaint investigations and compliance reviews as required by the HIPAA Regulations. 4. Accounting Of Disclosures. Although COUNTY and Contractor do not anticipate making disclosures other than for the purposes of this Agreement, COUNTY and Contractor will maintain records of a" disclosures of PHI made otherwise than for the purposes of this Agreement, including the date of the disclosure, the name and address (if known) of the reCipient of the PHI, a brief description of the PHI disclosed, and the purpose of the disclosure as necessary to permit Contractor and COUNTY to respond to a request by an individual for an accounting of disclosures in accordance with 45 CFR § 164.528. Each party will make such record available to the other party upon request. 5. Disclosure To U.S. Department Of Health And Human Services. Each party will make its internal practices, books, and records relating to the use and disclosure of PHI received from the other party (or created or received by one party on behalf of the other party) available to the Secretary of the United States Department of Health and Human Services, for purposes of determining County's and Contractor's compliance with the HIPAA Regulations. 6. Procedure Upon Termination. Upon termination of this Agreement, COUNTY and Contractor will, if feasible, return or destroy all PHI that the party maintains in any form, and will retain no copies of such PHI or, if the parties agree that return or destruction is not feasible, each party will continue to extend the protections of this exhibit to such PHI, and limit further use of the PHI to those purposes that make the return or destruction of the PHI infeasible. 7. No Third Party Beneficiaries. There are no third party beneficiaries to the Agreement or this exhibit. PAGE 2 OF 2 -EXHIBIT 3 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 Exhibit 4 DESCHUTES COUNTY SERVICES AGREEMENT Agreement No. 2013-364 Compliance with provisions, requirements of funding source and Federal and State laws, statutes, rules, regulations, executive orders and policies. Contractor shall comply with the following federal requirements. For the purposes of this Contract, all references to federal and state laws are references to federal and state laws as they may be amended from time to time. 1. Miscellaneous Federal Provisions. Contractor shall comply with all federal laws, regulations, and executive orders applicable to the Contract or to the delivery of Services. Without limiting the generality of the foregoing, Contractor expressly agrees to comply with the following laws, regulations and executive orders to the extent they are applicable to the Contract: (a) Title VI and VII of the Civil Rights Act of 1964, as amended, (b) Sections 503 and 504 of the Rehabilitation Act of 1973, as amended, (f) the Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of 1975, as amended, (g) the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, (h) all regulations and administrative rules established pursuant to the foregoing laws, (i) all other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations, and (j) all federal law governing operation of Community Mental Health Programs, including without limitation, all federal laws requiring reporting of Client abuse. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the Agreement and required by law to be so incorporated. No federal funds may be used to provide Services in violation of 42 U.S.C. 14402. 2. Equal Employment Opportunity. If this Contract, including amendments, is for more than $10,000, then Contractor shall comply with Executive Order 11246, entitled "Equal Employment Opportunity," as amended by Executive Order 11375, and as supplemented in Department of Labor regulations (41 CFR Part 60). 3. Clean Air, Clean Water, EPA Regulations. If this Contract, including amendments, exceeds $100,000 then Contractor shall comply with all applicable standards, orders, or requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended (commonly known as the Clean Water Act) (33 U.S.C. 1251 to 1387), specifically including, but not limited to Section 508 (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency regulations (2 CFR Part 1532), which prohibit the use under non-exempt Federal contracts, grants or loans of facilities included on the EPA List of Violating Facilities. Violations shall be reported to OHA, United States Department of Health and Human Services and the appropriate Regional Office of the Environmental Protection Agency. Contractor shall include in all contracts with subcontractors receiving more than $100,000, language requiring the subcontractor to comply with the federal laws identified in this section. 4. Energy Efficiency. Contractor shall comply with applicable mandatory standards and policies relating to energy efficiency that are contained in the Oregon energy conservation plan issued in compliance with the Energy Policy and Conservation Act 42 U.S.C. 6201 et. seq. (Pub. L. 94-163). 5. Truth in Lobbying. By signing this Contract, the Contractor certifies under penalty of perjury that the following statements are true to the best of the Contractors knowledge and belief that: a. No federal appropriated funds have been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any federal contract. grant, loan or cooperative agreement. PAGE 1 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 b. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan or cooperative agreement, the Contractor shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. c. The Contractor shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients and subcontractors shall certify and disclose accordingly. d. This certification is a material representation of fact upon which reliance was placed when this Contract was made or entered into. Submission of this certification is a prerequisite for making or entering into this Contract imposed by section 1352, Title 31 of the U.S. Code. Any person who ails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. e. No part of any federal funds paid to Contractor under this Contract shall be used other than for normal and recognized executive legislative relationships for publicity or propaganda purposes, for the preparation, distribution, or use of any kit, pamphlet, booklet, publication, electronic communication, radio, television, or video presentation designed to support or defeat the enactment of legislation before the United States Congress or any State or local legislature or legislative body, except in presentation to the Congress or any Stage or local legislature itself, or designed to support or defeat any proposed or pending regulation, administrative action, or order issued by the executive branch of any State or local government, except in presentation to the executive branch of any Sate or local government itself. f. No part of any federal funds paid to Contractor under this Agreement shall be used to pay the salary or expenses of any grant or contract reCipient, or agent acting for such reCipient, related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or Executive order proposed or pending before the United States Congress or any State government, State legislature or local legislature or legislative body, other than for normal and recognized executive-legislative relationships or partiCipation by an agency or officer of a State, local or tribal government in policymaking and administrative processes within the executive branch of that government. g. The prohibitions in subsections (b) and (c) of this section shall include any activity to advocate or promote any proposed, pending or future Federal, State or local tax increase, or any proposed, pending, or future requirement or restriction on any legal consumer product, including its sale or marketing, including but not limited to the advocacy or promotion of gun control. h. No part of any federal funds paid to Contractor under this Contract may be used for any activity that promotes the legalization of any drug or other substance included in schedule I of the schedules of controlled substances established under section 202 of the Controlled Substances Act except for normal and recognized executive congressional communications. This limitation shall not apply when there is significant medical evidence of a therapeutic advantage to the use of such drug or other substance or that federally sponsored clinical trials are being conducted to determine therapeutic advantage. 6. HIPAA Compliance. Contractor is a Covered Entity with respect to its healthcare components as described in OAR 943-014-0015 for purposes of the Health Insurance Portability and Accountability Act and the federal regulations implementing the Act (collectively referred to as HIPAA), and OAR 125-055 0100 through OAR 125-055-0130. Contractor must comply with HIPAA to the extent that any Services or obligations of Contractor arising under this Contract are covered by HIPAA. County shall determine if County will have access to, or create and protected health information in the performance of any Service or any other obligations under this Contract. To the extent that Contractor will have access to, or create any protected health information to perform functions, activities, or Services for, or on behalf of PAGE 2 OF 8-EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 a healthcare component of OHA in the performance of any Service required by this Contract, County shall comply and Contractor shall comply with OAR 125-055-0100 through OAR 125-055-0130 and the following: a. Privacy and Security of Individually Identifiable Health Information. Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health Information relating to speCific individuals may be exchanged between County and OHA for purposes directly related to the provision of Services to clients which are funded in whole or in part under this Contract. To the extent that Contractor is performing functions, activities, or services for, or on behalf of, a healthcare component of OHA in the performance of Services required by this Contract, Contractor shall not use or disclose any Individual Identifiable Health Information about specific individuals in a manner that would violate OHA Privacy Rules, OAR 943-014-0000 et. seq., or OHA Notice of Privacy Practices. A copy of the most recent OHA Notice of Privacy Practices may be obtained by contacting OHA or by looking up form number 2090 on the OHA web site at https:llapps.state.or.us/cf1/FORMS/. b. Data Transactions Systems. If County and Contractor intends to exchange electronic data transactions with a health care component of OHA in connection with claims or encounter data, eligibility or enrollment information, authorizations or other electronic transaction, County and Contractor shall execute an EDI Trading Partner Agreement and shall comply with OHA EDI Rules. c. Consultation and Testing. If County or Contractor reasonably believes that the County's or Contractor's data transactions system or other application of HIPAA privacy or security compliance policy may result in a violation of HIPAA requirements, County or Contractor shall promptly consult the OHA Information Security Office. County or Contractor may initiate a request for testing of HIPAA transaction reqUirements, subject to available resources and the OHA testing schedule. 7. Resource Conservation and Recovery. Contractor shall comply with all mandatory standards and policies that relate to resource conservation and recovery pursuant to the Resource Conservation and Recovery Act (codified at 42 U.S.C. 6901 et. seq.). Section 6002 of that Act (codified at 42 U.S.C. 6962) requires that preference be given in procurement programs to the purchase of specific products containing recycled materials identified in guidelines developed by the Environmental Protection Agency. Current guidelines are set forth in 40 CFR Part 247. 8. Audits. a. Contractor shall comply with applicable audit requirements and responsibilities set forth in this Contract and applicable state or federal law. b. Contractor shall also comply with applicable Code of Federal Regulations (CFR) and OMB Circulars governing expenditure of federal funds. Including, but not limited to, OMB A-133 Audits of States, Local Governments and Non-Profit Organizations. 9. Debarment and Suspension. County shall not permit any person or entity to be a contractor if the person or entity is listed on the non-procurement portion of the General Service Administration's "List of Parties Excluded from Federal Procurement or Nonprocurement Programs" in accordance with Executive Orders No. 12549 and No. 12689, "Debarment and Suspension". (See 2 CFR Part 180). This list contains names of parties debarred, suspended, or otherwise excluded by agencies, and contractors declared ineligible under statutory authority other than Executive Order No. 12549. Contractors with awards that exceed the simplified acquisition threshold shall provide the required certification regarding their exclusion status and that of their principals prior to award. 10. Drug-Free Workplace. Contractor shall comply with the following provisions to maintain a drug-free workplace: (i) Contractor certifies that it will provide a drug-free workplace by publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance, except as may be present in lawfully prescribed or over-the-counter medications, is prohibited in Contractor's workplace or while providing services to OHA clients. Contractor'S notice shall specify the actions that will be taken by Contractor against its employees for violation of such prohibitions; (ii) Establish a drug-free awareness program to inform its employees about: the dangers of PAGE 3 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 drug abuse in the workplace, County's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations; (iii) Provide each employee to be engaged in the performance of services under this contract a copy of the statement mentioned in paragraph (i) above; (iv) Notify each employee in the statement required by paragraph (i) above that, as a condition of employment to provide services under this Contract. the employee will: abide by the terms of the statement, and notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction; (v) Notify OHA within ten (10) days after receiving notice under subparagraph (iv) above from an employee or otherwise receiving actual notice of such conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted as required by Section 5154 of the Drug-Free Workplace Act of 1988; (vii) Make a good-faith effort to continue a drug-free workplace through implementation of subparagraphs (i) through (vii) above; (ix) Neither County. Contractor nor any of County's or Contractor's employees, officers, agents may provide any service required under this Contract while under the influence of drugs. For purposes of this provision, "under the influence" means: observed abnormal behavior or impairments in mental or physical performance leading a reasonable person to believe the County or Contractor's employee, officer, agent has used a controlled substance, prescription or non-prescription medication that impairs the County or Contractor, County or Contractor's employees, officers, agents performance of essential job function or creates a direct threat to OHA clients or others. Examples of abnormal behavior include, but are not limited to: hallucinations, paranoia or violent outbursts. Examples of impairments in physical or mental performance include, but are not limited to: slurred speech, difficulty walking or performing job activities; and (x) Violation of any provision of this section my result in termination of this Contract. 11. Pro-Children Act. Contractor shall comply with the Pro-Children Act of 1994 (codified at 20 U.S.C. section 6081 et. seq.). 12. Medicaid Services. To the extent Contractor provides any service whose costs are paid in whole or in part by Medicaid, Contractor shall comply with all applicable federal and state laws and regulation pertaining to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.C. Section 1396 et. seq., including without limitation: a. Keep such records as are necessary to fully disclose the extent of the services provided to individuals receiving Medicaid assistance and shall furnish such information to any state or federal agency responsible for administering the Medicaid program regarding any payments claimed by such person or institution for providing Medicaid Services as the state or federal agency may from time to time request. 42 U.S.C. Section 1396 a(a)(27); 42 CFR 431.107(b)(1) & (2). b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart (B). c. Maintain written notices and procedures respecting advance directives in compliance with 42 U.S.C. Section 1396(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 subpart I. d. e. Certify when submitting any claim for the provision of Medicaid Services that the information submitted is true, accurate and complete. Contractor shall acknowledge Contractor's understanding that payment of the claim will be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. Entities receiving $5 million or more annually (under this Contract and any other Medicaid Agreement) for furnishing Medicaid health care items or services shall, as a condition of receiving such payments, adopt written fraud, waste and abuse policies and procedures and inform employees, contractors and agents about the policies and procedures in compliance with Section 6032 of the Deficit Reduction Act of 2005, 42 U.S.C. § 1396a(a)(68). 13. ADA. Contractor shall comply with Title II of the Americans with Disabilities Act of 1990 (codified at 42 U.S.C. 12131 et. seq.) in the construction, remodeling, maintenance and operation of any structures and facilities, and in the conduct of all programs, services and training associated with the delivery of Services. PAGE 4 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 14. Agency-Based Voter Registration. If applicable, Contractor shall comply with the Agency-based Voter Registration sections of the National Voter Registration Act of 1993 that require voter registration opportunities be offered where an individual may apply for or receive an application for public assistance. 15. Disclosure. a. 42 CFR 455.104 requires the State Medicaid agency to obtain the following information from any contractor of Medicaid or CHIP services, including fiscal agents of providers and managed care entities: (1) the name and address (including the primary business address, every business location and P.O. Box address) of any person (individual or corporation) with an ownership or control interest in the provider, fiscal agent or managed care entity; (2) in the case of an individual, the date of birth and Social Security Number, or, in the case of a corporation, the tax identification number of the entity, with an ownership interest in the provider, fiscal agent or managed care entity or of any subcontractor in which the provider, fiscal agent or managed care entity has a 5% or more interest; (3) whether the provider, fiscal agent, or managed care entity is related to another person with ownership or control interest in the provider, fiscal agent or managed care entity as a spouse, parent, child or sibling; (4) the name of any other provider, fiscal agent or managed care entity in which an owner of the provider, fiscal agent or managed care entity has an ownership or control interest; and, (5) the name, address, date of birth and Social Security Number of any managing employee of the provider, fiscal agent or managed care entity. b. 42 CFR 455.434 requires as a condition of enrollment as a Medicaid or CHIP provider, to consent to criminal background checks, including fingerprinting when required to do so under state law, or by the category of the provider based on risk of fraud, waste and abuse under federal law. As such, a provider must disclose any person with a 5% or greater direct or indirect ownership interest in the provider whom has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years. c. OHA reserves the right to take such action required by law, or where OHA has discretion, it deems appropriate, based on the information received (or the failure to receive) from the provider, fiscal agent or managed care entity. 16. Special Federal Requirements Applicable to Addiction Services. a. Women's Services. If Contractor provides A&D 61 or A&D 62 Services, Contractor must: (1) Treat the family as a unit and admit both women and their children if appropriate. (2) Provide or arrange for the following services to pregnant women and women with dependent children: (a) Primary medical care, including referral for prenatal care; (b) Pediatric care, including immunizations, for their children; (c) Gender-specific treatment and other therapeutic interventions, e.g. sexual and phYSical abuse counseling, parenting training, and child care. (d) Therapeutic interventions for children in custody of women in treatment, which address, but are not limited to, the children's developmental needs and issues of abuse and neglect; and (e) Appropriate case management services and transportation to ensure that women and their children have access to the services in (a) through (d) above. b. Pregnant Women. If Contractor provides any A&D Services other than A&D 70 Services, Contractor must: PAGE 5 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 (1) Within the priority categories, if any, set forth in a particular Service Description, give preference in admission to pregnant women in need of treatment who seek, or are referred for, and would benefit from, such services; (2) Perform outreach to inform pregnant women of the availability of treatment services targeted to them and the fact that pregnant women receive preference in admission to these programs; (3) If Contractor has insufficient capacity to provide treatment services to a pregnant woman, refer the women to another provider with capacity or if no available treatment capacity can be located, refer the women to OHA's Addictions and Mental Health Division for referral to another provider in the state. If capacity cannot be located, AMH will make available interim services within 48 hours, including a referral for prenatal care. c. Intravenous Drug Abusers. If Contractor provides any A&D Services other than A&D 70 Services, Contractor must: (1) Within the priority categories, if any, set forth in a particular Service Description and subject to the preference for pregnant women described above, give preference in admission to intravenous drug abusers; (2) Programs that receive funding under the grant and that treat individuals for intravenous substance abuse, upon reaching 90 percent of its capacity to admit individuals to the program, must provide notification of that fact to the State within seven days. (3) If Contractor receives a request for admission to treatment from an intravenous drug abuser, Contractor must, unless it succeeds in referring the individual to another provider with treatment capacity, admit the individual to treatment not later than: (a) 14 days after the request for admission to Contractor is made; or (b) 120 days after the date of such request if no provider has the capacity to admit the individual on the date of such request and, if interim services are made available not less than 48 hours after such request. (4) For the purposes of (3) above, "Interim Services" means: (a) Services for reducing the adverse health effects of such abuse, for promoting the health of the individual, and for reducing the risk of transmission of disease, including counseling and education about HIV and tuberculosis, the risks of needle sharing, the risks of transmission of disease to sexual partners and infants, and steps that can be taken to ensure that HIV and tuberculosis transmission does not occur; (b) Referral for HIV or TB treatment services, where necessary; and (c) Referral for prenatal care if appropriate, until the individual is admitted to a provider's services. (d) If Contractor treats recent intravenous drug users (those who have injected drugs within the past year) in more than one-third of its capacity, Contractor shall carry out outreach activities to encourage individual intravenous drug abusers in need of such treatment to undergo treatment, and shall document such activities. d. Infectious Diseases. If Contractor provides any A&D Services other than A&D 70 Services, Contractor must: PAGE 6 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 (1) Complete a risk assessment for infectious disease including Human Immunodeficiency Virus (HIV) and tuberculosis, as well as sexually transmitted diseases, based on protocols established by OHA, for every individual seeking Services from County; and (2) Routinely make tuberculosis services available to each individual receiving Services for alcohol/drug abuse either directly or through other arrangements with public or non-profit entities and, if Contractor denies individual admission on the basis of lack of capacity, refer the individual to another provider of tuberculosis Services. (3) For the purposes of (2) above, "tuberculosis services" means: (a) Counseling the individual with respect to tuberculosis; (b) Testing to determine whether the individual has contracted such disease and testing to determine the form of treatment for the disease that is appropriate for the individual; and (c) Appropriate treatment services. e. OHA Referrals. If Contractor provides any A&D Services other than A&D 70 services, Contractor must, within the priority categories, if any, set forth in a particular Service Description and subject to the preference for pregnant women and intravenous drug users described above, give preference in A&D service delivery to persons referred by OHA. f. Barriers to Treatment. Where there is a barrier to delivery of an A&D Service due to culture, gender, language, illiteracy, or disability, Contractor shall develop support services available to address or overcome the barrier, including: (1) Providing, if needed, hearing impaired or foreign language interpreters. (2) Providing translation of written materials to appropriate language or method of communication. (3) Providing devices that assist in minimizing the impact of the barrier. (4) Not charging clients for the costs of measures, such as interpreters, that are required to provide nondiscriminatory treatment. g. Misrepresentation. Contractor shall not knowingly or willfully make or cause to be made any false statement or representation of a material fact in connection with the furnishing of items or Services for which payments may be made of OHA h. Oregon Residency. A&D Services funded through this Contract may only be provided to residents of Oregon. Residents of Oregon are individuals who live in Oregon. There is no minimum amount of time an individual must live in Oregon to qualify as a resident so long as the individual intends to remain in Oregon. A child's residence is not dependent on the residence of his or her parents. A child living in Oregon may meet the residency requirement if the caretaker relative with whom the child is living is an Oregon resident. i. Tobacco Use. If Contractor has A&D Services treatment capacity that has been deSignated for children, adolescents, pregnant women, and women with dependent children, Contractor must implement a policy to eliminate smoking and other use of tobacco at the facilities where the Services are delivered on the grounds of such facilities. j. Client Authorization. Contractor must comply with 42 CFR Part 2 when delivering an Addiction Service that includes disclosure of Client information for purposes of eligibility determination. Contractor must obtain Client authorization for disclosure of billing information, to the extent and in the manner required by 42 CFR Part 2, before a Disbursement Claim is submitted with respect to delivery of an Addiction Service to that individual. PAGE 7 OF 8 EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 17. Community Mental Health Block Grant. All funds, if any, awarded under this Contract for MHS 20, MHS 22, MHS 37 or MHS 38 Services are subject to the federal use restrictions and requirements set forth in Catalog of Federal Domestic Assistance Number 93.958 and to the federal statutory and regulatory restrictions imposed by or pursuant to the Community Mental Health Block Grant portion of the Public Health Services Act, 42 U.S.C. 300x-1 et. seq., and Contractor shall comply with those restrictions. 18. Substance Abuse Prevention and Treatment. To the extent Contractor provides any Service whose costs are paid in whole or in part by the Substance Abuse, Prevention, and Treatment Block Grant, Contractor shall comply with federal rules and statutes pertaining to the Substance Abuse, Prevention, and Treatment Block Grant, including the reporting provisions of the Public Health Services Act (42 U.S.C. 300x through 300x-66). Regardless of funding source. to the extent Contractor provides any substance abuse prevention or treatment services, Contractor shall comply with the confidentiality requirements of 42 CFR Part 2. PAGE 8 OF 8 -EXHIBIT 4 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 Exhibit 5 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-364 CONFIDENTIALITY AGREEMENT county will make available and/or transfer to Contractor certain Information, in conjunction with goods or services that are being provided by Contractor to County that is confidential and must be afforded special treatment and protection. Contractor will have access to and/or receive from County certain Information that can be used or disclosed only in accordance with this Agreement and the HHS Privacy Regulations. To the extent required by 42 U.S.C. 1171 et seq. enacted by the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder, Contractor assures County that Contractor will appropriately safeguard protected health information made available to or obtained by Contractor. Contractor further agrees to comply with applicable laws relating to protected health information and with respect to any task or other activity Contractor performs on behalf of County, to the extent County would be required to comply with such requirements. For purposes of this Agreement, the following terms shall apply: A. Contractor shall be considered a Contractor; B. County shall be considered a COVERED ENTITY; C. HHS Privacy Regulations shall mean the Code of Federal Regulations (C.F.R.) at Title 45, Sections 160 and 164; D. Individual shall mean the person who is the subject of the Information, and has the same meaning as the term 'individual' is defined by 45 C.F.R. 164.501; and E. Secretary shall mean the Secretary of the Department of Health and Human Services (HHS) and any other officer or employee of HHS to whom the authority involved has been delegated; F. Information shall mean any health information provided and/or made available by County to Contractor, and has the same meaning as the term 'health information' as defined by 45 C.F.R. 160.102. Contractor agrees it shall: 1. Not use or further disclose such information other than as permitted or required by this Agreement Contractor shall not, except as necessary for the proper management, administration and performance of its duties under this Agreement, use, reproduce, disclose, or provide to third parties, any confidential document or information relating to the County, its members or to Individuals seeking services from County or its members without the prior written consent or authorization of the County or of the Individual. If Contractor uses such information for the purposes set forth above, it will only do so if the disclosure is required by law or Contractor obtains reasonable assurances from the person to whom the information is disclosed that it will be held confidentially and used or further disclosed only as required by law or for the purpose for which Contractor disclosed it to the person. Contractor shall ensure that its personnel, employees, affiliates and agents maintain the confidentiality of patient health information and business information of County. PAGE 1 OF 2 -EXHIBIT 5 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 2. Not use or further disclose the information in a manner that would violate the requirements of applicable law, if done by County; 3. Use appropriate safeguards to prevent use or disclosure of such information other than as provided for by this Agreement; 4. Report to County any use or disclosure of such information not provided for by this Agreement of which Contractor becomes aware; 5. Ensure that any subcontractors or agents to whom Contractor provides protected health information received from County agree to the same restrictions and conditions that apply to Contractor with respect to such information; 6. Make available protected health information in accordance with applicable law, i.e., the Code of Federal Regulations (C.F.R.) at Title 45, Sections 160 and 164; 7. Maintain standard records, pursuant to this Agreement, and to provide such records and other necessary information to the County as may be requested in writing and as permitted by law. Contractor agrees that all records kept in connection with this agreement are subject to review and audit by the County upon reasonable notice of a minimum of 14 work days from the date of written request by the County. "'" 8. Make Contractor's internal practices, books, and records relating to the use and disclosure of "-- protected health information received from County available to the Secretary of the United States Health & Human Services for purposes of determining County's compliance with applicable law (in all events, Contractor shall immediately notify County upon receipt by Contractor of any such request, and shall provide County with copies of any such materials); 9. Upon termination of this Agreement, Contractor shall promptly return all protected health information received from County. If the return of protected health information is not feasible, Contractor shall continue the protections required under this contract to the protected health information consistent with the requirements of this Attachment and the HIPAA privacy standards. ~n~lj?'18 Signature I/J1If!dttI Title S v(Jfc.Fb PAGE 2 OF 2 -EXHIBIT 5 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 Exhibit 6 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013 REQUIRED PROVIDER CONTRACT PROVISIONS Oregon Health Authority Exhibit I of 2013-2015 Intergovernmental Agreement 1. Expenditure of Funds. Contractor may expend the funds paid to Contractor under this Contract solely on the delivery of services as described in Exhibit 1 of this Contract ("Services"), subject to the following limitations (in addition to any other restrictions or limitations imposed by this Contract): a. Contractor may not expend on the delivery of Services any funds paid to Contractor under this Contract in excess of the amount reasonable and necessary to provide quality delivery of Services. b. If this Contract requires Contractor to deliver more than one service, Contractor may not expend funds paid to Contractor under this Contract for a particular service on the delivery of any other service. c. If this Contract requires Contractor to deliver alcohol, drug abuse and addiction services, Contractor may not use the funds paid to Contractor under this Contract for such services: (1) To provide inpatient hospital services; (2) To make cash payments to intended recipients of health services; (3) To purchase or improve land, to purchase, construct or permanently improve (other than minor remodeling) any building or other facility or to purchase major medical equipment; (4) To satisfy any requirement for expenditure of non-federal funds as a condition for receipt of federal funds (whether the federal funds are received under this Contract or otherwise); (5) With respect to federal Substance Abuse Prevention and Treatment Block Grant moneys only, to purchase services from any person or entity other than a public or non-profit entity; or (6) To carry out any program prohibited by section 245(b) of the Health Omnibus Programs Extension Act of 1988 (codified at 42 U.S.C. 300ee(5). d. Contractor may expend funds paid to Contractor under this Contact only in accordance with federal OMB Circular A-87 as that circular is applicable on allowable costs. 2. Records Maintenance, Access and Confidentiality. a. Access to Records and Facilities. County, the Oregon Health Authority, the Secretary of State's Office of the State of Oregon, the Federal Government, and their duly authorized representatives shall have access to the books, documents, papers and records of Contractor that are directly related to this Contract, the funds paid to Contractor hereunder, or any services delivered hereunder for the purpose of making audits, examinations, excerpts, copies and transcriptions. In addition, Contractor shall permit authorized representatives of County and the Oregon Health Authority to perform site reviews of all services delivered by Contractor hereunder. b. Retention of Records. Contractor shall retain and keep accessible all books, documents, papers, and records, that are directly related to this Contract, the funds paid to Contractor hereunder or to any services delivered hereunder, for a minimum of six (6) years, or such longer period as may be required by other provisions of this Contract or applicable law, following the termination or expiration of this Contract. If there are unresolved audit or other questions at the end of the six-year period, Contractor shall retain the records until the questions are resolved. c. Expenditure Records. Contractor shall document the expenditure of all funds paid to Contractor under this Contract. Unless applicable federal law requires Contractor to utilize a different Accounting system, Contractor shall create and maintain all expenditure records in accordance with generally accepted accounting principles and in sufficient detail to permit County and the Oregon Health Authority to verify how the funds paid to Contractor under this Contract were expended. PAGE 1 OF 4 -EXHIBIT 6 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 d. Individual Records. Unless otherwise specified in this Contract, Contractor shall create and maintain an Individual record for each Individual who receives services under this Contract. The Individual record must contain: (1) Individual's identification; (2) Problem assessment; (3) Services and supports, training and/or care plan; (4) Medical information when appropriate; and (5) Service notes including service conclusion summary and current assessment or evaluation instrument as designated by the Oregon Health Authority in administrative rules. Contractor shall retain Individual records in accordance with OAR 166-150-0005 through 166 150-0215 (State Archivist). Unless OAR 166-150-0005 through 166-150-0215 requires a longer retention period, Individual records must be retained for a minimum of ten (10) years from termination or expiration of this Contract. e. Safeguarding of an Individual's Information. Contractor shall maintain the confidentiality of records of Individual's as required by applicable state and federal law, including without limitation, ORS 179.495 to 179.507, 45 CFR Part 205,42 CFR Part 2, any administrative rule adopted by the Oregon Health Authority, implementing the foregoing laws, and any written policies made available to Contractor by County or by the Oregon Health Authority. Contractor shall create and maintain written policies and procedures related to the disclosure of Individual's information, and shall make such policies and procedures available to County and the Oregon Health Authority for review and inspection as reasonably requested by County or the Oregon Health Authority. f. Data Reporting. All individuals receiving services with funds provided under this Contract must enroll and maintain that client's record in either: (1) The Client Processing Monitoring System (CPMS) as specific in OHA's CPMS manual located at: http://www.oregon.gov/OHAlamh/training/cpms/index.shtml.asit may be revised from time to time; or (2) The Measures and Outcome Tracking System (MOTS) as specified in OHA's MOTS manual located at: http://www.oregon.gov/oha/amh/pages/compass/electronic-data-capture.aspx, as may be revised from time to time. Over the next two years AMH will be closing the CPMS system and replacing it with the MOTS system. Providers will be notified of the change. 3. Alternative Formats of Written Materials. In connection with the delivery of Services, Contractor shall: a. Make available to an Individual, without charge to the Individual, upon the Individual's, the County's or the Oregon Health Authority's request, any and all written materials in alternate, if appropriate, formats as required by the Oregon Health Authority's administrative rules or by the Oregon Health Authority's written policies made available to Contractor. b. Make available to an Individual, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, any and all written materials in the prevalent non-English languages in the area served by Contractor. c. Make available to a Individual, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, oral interpretation services in all non-English languages in the area served by Contractor. d. Make available to a Individual with hearing impairments, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, sign language interpretation services and telephone communications access services. For purposes of the foregoing, "written PAGE 2 OF 4 -EXHIBIT 6 TO PERSONAL SERVICES CONTRACT No. 2013-364 materials· includes, without limitation, all written materials created or delivered in connection with the services and all subcontractor contracts related to this Contract. 4. Reporting Requirements. Contractor shall prepare and furnish the following information to County and the Oregon Health Authority when a service is delivered under this Contract: a. Individual, service and financial information as specified in the applicable service description attached hereto and incorporated herein by this reference. b. All additional information and reports that County or the Oregon Health Authority reasonably requests, including, but not limited to, the information or disclosures described in Exhibit 4, Required Federal Terms and Conditions, Section 15, Disclosure.. 5. Compliance with Law. Contractor shall comply with all state and local laws, regulations, executive orders and ordinances applicable to the Contract or to the delivery of services hereunder. Without limiting the generality of the foregoing, Contractor expressly agrees to comply with the following laws, regulations and executive orders to the extent they are applicable to the Contract: (a) all applicable requirements of state civil rights and rehabilitation statutes, rules and regulations; (b) all state laws governing operation of community mental health programs, including without limitation, all administrative rules adopted by the Oregon Health Authority related to community mental health programs; (c) all state laws requiring reporting of abuse of an Individual; (d) ORS 659A400 to 659A409, ORS 659A 145 and all regulations and administrative rules established pursuant to those laws in the construction, remodeling, maintenance and operation of any structures and facilities, and in the conduct of all programs, services and training associated with the delivery of services under this Contract. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the Contract and required by law to be so incorporated. All employers, including Contractor, that employ subject workers who provide services in the State of Oregon shall comply with ORS 656.017 and provide the required Workers' Compensation coverage, unless such employers are exempt under ORS 656.126. In addition, Contractor shall comply, as if it were County thereunder, with the federal requirements set forth in Exhibit H to the certain 2013 2015 Intergovernmental Agreement for the Financing of Community Addictions and Mental Health Services between County and the Oregon Health Authority dated as of July 1, 2013, which Exhibit is incorporated herein by this reference. For purposes of this Contract, all references in this Contract to federal and state laws are references to federal and state laws as they may be amended from time to time. 6. Unless Contractor is a State of Oregon governmental agency, Contractor agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Health Authority or County 7. To the fullest extent permitted by applicable law, Contractor shall defend (in the case of the state of Oregon and the Oregon Health Authority, subject to ORS Chapter 180), save and hold harmless the State of Oregon, the Oregon Health Authority, County, and their officers, employees, and agents from and against all claims, suits, actions, losses, damages, liabilities, costs and expenses of any nature whatsoever resulting from, arising out of or relating to the operations of the Contractor, including but not limited to the activities of Contractor or its officers, employees, subcontractors or agents under this Agreement. 8. Contractor understands that Contractor may be prosecuted under applicable federal and state criminal and civil laws for submitting false claims, concealing material facts, misrepresentation, falsifying data system input, other acts of misrepresentation, or conspiracy to engage therein. 9. Contractor shall only conduct transactions that are authorized by the County for transactions with the Oregon Health Authority that involve County funds directly related to this Contract. PAGE 3 OF 4 EXHIBIT 6 TO PERSONAL SERVICES CONTRACT No. 2013-364 10. Contractor(s) that are not units of local government as defined in ORS 190.003 shall obtain, at Contractor's expense, and maintain in effect with respect to all occurrences taking place during the term of the Contract, insurance requirements as specified in Exhibit 2 of this Agreement. 11 Contractor(s) that are not units of local government as defined in ORS 190.003, shall indemnify, defend, save and hold harmless the State of Oregon and its officers, employees and agents ("Indemnitee") from and against any and all claims, actions, liabilities, damages, losses, or expenses (including attorneys' fees) arising from a tort (as now or hereafter defined in ORS 30.260) caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Provider or any of the officers, agents, employees or subcontractors of the contractor( "Claims"). It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by the Contractor from and against any and all Claims. 12. Contractor shall include sections 1 through 11, in substantially the form set forth above, in all permitted Contractor contracts under this Contract. Date: !).&t/r.3 Signature:~ Title ~vf,IcFb Contra or I PAGE 4 OF 4 -EXHIBIT 6 -DESCHUTES COUNTY SERVICES AGREEMENT No. 2013-364 l [)ATE (IU'IDOIYYYY)ACORD· 0612712013~. CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER.TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TH~S CERTIFICATE OF INSURANce DOES NOT CONSTITUTE A CONTRACT BETWeEN THE ISSUING INSURER(S). AUTHORIZeD REPRESENTAnvE OR PRODOCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If Ule ~rtific;ate hQlder is an ADDITIONAL INSURED, the policy(Ies;) rnullt be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy. certaIn polich. may require an endorsement. A statement on this certlflcafe dOIl$ not confer rights to the certlflcate holder In lieu of such 8rn:1orsemenl(s). PRODUCIiR I~~CT MARSH RISK & INSURANCE SERVICES 345 CAUfORNIA STREET, SUITE 1300 __J~.".I; CAUFORNIA liCENSE NO. 0437153 It:' -----SAN FRANCISCO. CA 94104 HAle.INSIlRERI~AFFOIU)ING COVERAGEAttn: SanFranclsto.Carls@mri.oomlt 212·94s.tl393 --. 17310"SURER A • Nautilus Inwrance Cofl1lanr~~TELCo-GAwuP·1tI4 ____~ we OR .-INI!URI!O rl~SURER IU.__.__TELECARE MENTAl. HEAlTH SERVICES OF OREGON, INC. INSURERC: 1080 MARINA VlUAGE PARWNI\Y, Stm! 100 180SSINSURER II : Pbnad~hla indemnIty In$llta/1C8 ~paIly ,.ALAMEDA. CA 94501 15105INs.uRI!lI E: Salety National Casualty COrp.-'=_._-. INSUII£R 1'; COVERAGES CERTIFICATE NUMBER' REVISION NUMBER' e THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED Be~OW HAVE BEEN ISSUED TO THE INSt,JRED NAMED ABOVE FOR THE POUCY PERIOD INDICATED'. NOTWITHSTANDING ANY REQUIREMENT,' TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wmt RESPIlCT TO 'M1tCH THIS CERTIFICATE MAY BIl ISSUIlD OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE 01' INSURANce r.~I= POI..ICY NUMBER J~,!:.IiI''' POUCYEXP UN1lSLTR A GENERAL UABIUlY GFPlOOOOQ3P5 01m/2013 0710112014 !~ $ 1,000,000 ,....,... ~tW.e1 .100,000~DMERCIN.GENeRAL UAIliUTY $ '7.'" ClAlUS-MAOE 0 OCCUR MEDlOO>{Mt .....,.""", 1$ 5,000 ~SIR: $100,000 J'i'RSONAI. 'NJV INJURY $ 1.000,000 f-J ~~g(il\TI; $ 3.000,000 ~III'LAGGRrI;LIMIT nSPER; PRODUCTS. COMPiOP 1\00 S 1,000,000 x I'OI.JCY ~ Loe $ 0 AUTOllOllll.E UABIUlY PHPK1040219 01~1J2013 01101121l14 ,UMII '. ~~ -:: X wYAUTO IlOOllVINJVRY (Per poroon) $ -All OWNED C SCHEDULED I BODILY INJURY (PeI-~ $ _ AUTOS AJJl'OSrx OOW-OIMED ~Pe~i:W.iAGc s _.,.,HIRED AUTOS AUTOS I ..X Comp: $500 X Col: $1000 $ UMBRaI..A UMJ t-l~:~ I EACIi ClCCURRENCE $-'I EX(;ESSUAII Al3GREGATE , OED I ! RETl!NTION $ I $ E WO_S COMPefSATIOH I LD~l4 0711l1t.!013 ()71\l11201~ X IT">£mWi.. I I°JitAND EMPLOYeRS' UA8IUlY V I III Oed: $250.000 1,000.000J,Jof'( PROPRIETORJPMTN1iRIEXECIJT1VE 0 i E.l. EACH ACCIDENT •OfFICElWi:MlIIOl<,~? N I A E.l. PrSEASE· EA EMPLOYE!! $ 1.000.000,_.tory In NH) ~ ~"k~~TlClNS_ E.l. DISEASE. POUCY UMlT , 1,000,000 A HEAlTHCARE PROF. lIABIUlY PFP1000081PS 0710112013 07111112014 AGGREGATE 3,000,000 ClNMSIMOE; SIR; $1()(l,000 AGGREGATE 3,000,000 oescRIP'I'ION ()EI OPEAA'I1ONS J LOCATIONS I VEHICLES IU,,,, ACORD 101, AdcflUo,,", _n..o _"""" if mOl'l ."...Jo re",,1mIi DESCHUTES COUNTY, ITS OFFICERS, AGENTS, EMPlOYEES. AND VOlllNTI:ERSARE ADOITIQNAlIIISUREDS UNDER TI1E GENERAl UABllilY AND AUTOIoIOBILE lIAllIUTY POUC1ES $OlE\.Y AS RESPE'CTS WORKPERFORMEO BY OR FOR THE NAilED INSURED IN CONNECTION WITlI THE CONTRACT AGREliMEIfT. "!HIS INSVRANCE IS PRlt.IARV "HO NON'(x)N'I'ImIJTORY OVER ANY EXlSnNG INSURAtCE AND UUITED TO lWllUTV ARISING OUT OF Tt!E. OPERATIONS OF THE KAI.!EO INSURED AIIO WHERE REQUIRED BYWRlTTEN CON'tRAC1. CERTIFICATE HOLDER CANCELLATION DESCHUTES COUNTY HEAlTH SERVICES 2577 HE COURTNEY ORIVE BENO, OR 97702 SHOULD ANY OF THE ABOV£ DESCRIBED POLICIES BE CANCElLEO BEFORE THE EXPIRATION DATE THEREOF, Nonce WILL BE OeU\/ERI!D IN ACCORDANCE WITH THE POUCY PROVISIONS. I Al!lM(lItI%ED IIEl'RESeHTATMi of M_RI.k ~Insuran"" SeMe_ Ellen Reda. BlOWn ~ @1988-2010ACORD CORPORATION, All rights reEierved, ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD . AGENCY CUSTOMER 10: ....:O::.!.7=262~4~._____________ Loe;ll: San Francisco .,......--.., II> ACORD ADDITIONAL REMARKS SCHEDULE Page _2_of_2_ ~ AGeNCY W.RSH RISK & INSURANCE SERVICES ~. NAIIEDINSU~ TaECAAE MENTAL HEALTH SERVICES Of OREGON,INC. 1000 llARlNA VILlAGE PARKWAY, StJITE 100POLICY HUMBER AlAlo4EDA, CiA 94501 CARRIER iNAICCOD!! EFFECTIVE DAm ADDlTfONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE; Certificate of Liability InSlUrance Otbet Umils EACH OCCURRENCe: 1,000,000 SEXUAl. ABuse CQ\lERAGE 1.:. HiUti,LI$ \llsUO'arce Company Poley No.: PfPl00008IP5 Ncy POI1od: 07101/2013· 07l:!1r20H I I [ I I I!; I I I ACORD 101 (2008101) ® 2008 ACORD CORPORATION. A II rights reservec:J. The ACORD (lame iilnd logo tire regiatered merks of ACORD ;. I~ I:: Ii THIS ENDORSEMENT CHANGES THE POLlCY_ PLEASE READ IT CAREFULLY, ~~ I I"1 I. I FJ~ADDITIONAL INSURED -AUTOMATIC STATUS WHEN ~;. f'!:~'.REQUIRED'IN AGREEMENT WITH YOU i. I ~. ,. ~~ r~~ i F:ThIs endornement modifies insurance provided under the following: i. HEALTHCARE GENERAL LIABIUTY COVERAGE FORM :'>:: A. Section 11-Who Is An Insured Is amended to Include as an ?ddltloll3llnsured any person or orgmation 1 t~ , br whom you are performing operations when you and such person or organization have agreed In wrlllng in ~~ a contract or agreement Ihat such person or organization be added as an additional Insured tlI1 your policy.. J ! W· ..;iSuch person or organk:ation Is an additional insured only with respect 10 lIablUly for "bodi[y iIlury". ·props tty I ~ .damage-or ·personal and advertising injury" caused In whole or In part. by: !:. L 1·, Your acls or omissIons; or "f. 2. The acts or omisSions of those acting. on your behalf; ~:~ In the penonnance of your ongoing operations for the addltfonal insured. Aperson's or organization's status as an addi!lonal insured under this endors~ment ends wh~n your ~ operations for that additional insured are completed. I I ~ 1 ~ ~ ! [~ i ~ j .1 ~ .~ l ~ .1 s~ NOTHING CONTAINED HEREIN SHALL VARY, At-TER; WAIVE OR EXTEND ANY OF THE TERMS,1 .PROVISIONS. REPRESENTATIONS, CONDmONS OR AGREEMENTS OF THE POLICY OTHER THA.N AS STATED ABove. . . 1; J ;t '; SSM-0061(7!07) lnc/u\le3 copyrigh1ed material of Insurance S~S Office., Inc. wllh its Pege 1 011 perml~on.~ .1 ., .~• ,j 1 I l 1 I i